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EVALUATION OF THE EFFICACY OF MUSHKAKADI YOGA IN STHOULYA, BY shekhar Shakti sharma, Department of Kayachikitsa, Post graduate studies and research center D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, ...

EVALUATION OF THE EFFICACY OF MUSHKAKADI YOGA IN STHOULYA, BY shekhar Shakti sharma, Department of Kayachikitsa, Post graduate studies and research center D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, Gadag - 582 103

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    • “EVALUATION OF THE EFFICACY OF MUSHKAKADI YOGA IN STHOULYA” BY Dr. SHEKHAR SHAKTI SHARMA Dissertation Submitted to the Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka. In partial fulfilment of the degree of AYURVEDA VACHASPATI IN KAYACHIKITSA Under the guidance of DR. SHETTAR. R. V. M.D. (AYU) Asst. Professor P.G. Dept. of Kayachikitsa POST GRADUATE DEPARTMENT OF KAYACHIKITSA D.G M.AYURVEDIC MEDICAL COLLEGE AND RESEARCH CENTER GADAG – 582103 2005-2008
    • DECLARATION BY THE CANDITATE I hereby declare that this dissertation / thesis entitled “EVALUATION OFTHE EFFICACY OF MUSHKAKADI YOGA IN STHOULYA’” is a bonafide andgenuine research work carried out by me under the guidance of Dr. Shettar R. V.M.D. (Ayu), Asst. Professor, Post Graduate Department of Kayachikitsa, Shri D.G.M.Ayurvedic Medical College, Gadag.Date: Signature of the CandidatePlece: Gadag : (Dr. SHEKHAR SHARMA.)
    • CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “EVALUATION OF THEEFFICACY OF MUSHKAKADI YOGA IN STHOULYA” is a bonafide researchwork done by Dr. SHEKHAR SHARMA, in partial fulfillment of the requirementfor the degree of Ayurveda Vachaspathi. M.D. (Kayachikitsa).Date: Signature of the GuidePlace: Gadag Dr. SHETTAR. R. V. M.D. (Ayu) Asst. Prof. P.G. Dept of Kayachikitsa Shri. D.G.M. Ayurvedic Medical College, Gadag.
    • COPYRIGHT Declaration by the Candidate I here by declare that the Rajiv Gandhi University of Health Sciences,Karnataka shall have the rights to preserve, use and disseminate this dissertation /thesis in print or electronic format for academic / research purpose.Date: Signature of the CandidatePlace: Gadag. Dr. SHEKHAR SHAKTI SHARMA. © Rajiv Gandhi University of Health Sciences, Karnataka.
    • TABLE OF CONTENTSChapters Page No.1. Introduction 01-042. Objectives 05-083. Review of Literature 17-794. Methodology 80-865. Observation and Results 87-1106. Discussion 111-1277. Conclusion 128-1308. Summary 131-1339. Bibliography 134-14810. Annexure vii
    • List of TablesSl. Tables PageNo. No.1 Showing Aharaja Nidana 202 Showing Viharaja Nidana 213 Showing Manasika Nidana 214 Showing Anya Nidana 215 Showing Rupas of Sthoulya described in Ayurvedic texts 356 Showing Pramana Pariksha 377 Showing Normal Height & Weight 38-398 Showing Grading Pattern as per BMI values 399 Showing Optimal BMI values 39-4010 Showing Upadrava of Sthoulya 5311 Showing Sadhyasadhyata of Sthoulya 5612 Showing Methods of Samsodhana therapy of Sthoulya 5913 Showing Pathya of Sthoulya 71-7314 Showing Aharaja Pathyapathya 73-7415 Showing Viharaja Pathyapathya 7416 Showing Manasika Pathyapathya 7417 Showing Components Mushkakadi Yoga 7518 Showing Properties of Ingredients of Mushkakadi Yoga 76-7719 Showing Dosha & Roga prabhava, Chemical composition and Action 77-79 of Trial Drugs20 Showing the Materials used for Lipid Profile 8321 Showing the age wise distribution of total patients 8822 Showing the sex wise distribution of total patients with percentage 8923 Showing the religion wise distribution of total patients with 89 percentage24 Showing the occupation wise distribution of total patients with 90 percentage25 Showing the marital status wise distribution of total patients with 91 percentage26 Showing the intake rasa predominance wise distribution of total 91 patients with percentage27 Showing the nidra wise distribution of total patients with percentage 9228 Showing the Vyasana wise distribution of total patients with 93 percentage29 Showing the Diet wise distribution of total patients with percentage 9430 Showing the Shareera Prakritti wise distribution of total patients with 94 percentage31 Showing the Sara wise distribution of total patients with percentage 9532 Showing the Samhanana wise distribution of total patients with 96 percentage33 Showing Satwa wise distribution of total patients with percentage 9634 Showing Vyayama shakti wise distribution of total patients with 97 percentage35 Showing Pramana wise distribution of total patients with percentage 9836(B) Showing Jarana Shakti wise distribution of total patients 99 viii
    • 37 Showing Jathragni wise distribution of total patients with percentage 10038 Showing Koshta wise distribution of total patients with percentage 10039 Showing Family history wise distribution of total patients with 101 percentage40 Showing Vyayama wise distribution of total patients with percentage 10241 Showing Weight wise distribution of total patients with percentage 10242 Showing incidence of BMI in total patients with percentage 10343 Showing incidence of chief complaints of Sthoulya in total patients 104 with percentage44 Showing incidence of associated complaints of Sthoulya with 105 percentage45 Showing the incidence of the type of Obesity in total patients 10546 Showing the statistical analysis of individual subjective parameters to 110 show the significance effect before and after the treatment47 Showing the statistical analysis of individual objective parameters to 110 show the significance effect before and after the treatment48 Showing the statistical analysis of Lipid profile before and after the 111 treatment List of Graphs, Flow charts, Figures and PhotographsSl.No. Title of Graphs Page No.1 Graph showing age wise distribtion of total patients 882 Graph showing sex wise distribution of total 25 patients 893 Graph showing religion wise distribution of total patients 904 Graph showing occupation wise distribution of total patients 905 Graph showing marital status wise distribution of total patients 916 Graph showing intake rasa predominance wise distribution of total 92 patients7 Graph showing nidra wise distribution of total patients 938 Graph showing Vyasana wise distribution of total patients 939 Graph showing diet wise distribution of total patients 9410 Graph showing shareera prakritti wise distribution of total patients 9511 Graph showing sara wise distribution of total patients 9512 Graph showing samhanana wise distribution of total patients 9613 Graph showing satwa wise distribution of total patients 9714 Graph showing vyayama shakti wise distribution of total patients 9715 Graph showing pramana wise distribution of total patients 98 ix
    • 16-A Graph showing Abhyavarana Shakti wise distribution of total 99 patients16-B Graph showing Jarana Shakti wise distribution of total patients 9917 Graph showing jatharagni bala wise distributon of total patients 10018 Graph showing kostha wise distribution of total patients 10119 Graph showing family history wise distribution of total patients 10120 Graph showing vyayama wise distribution of total patients 10221 Graph showing weight wise distribution of total patients 10322 Graph showing the incidence of BMI in total patients 10323 Graph showing symptom wise distribution of total patients 10424 Graph showing associated complaint wise distribution of total 105 patients25 Graph showing the incidence of type of Obesity in total patients 106Sl.No. Title of Flow Chart Pg.No1 Showing the schematic representation of samprapti of Sthoulya 452 Showing the schematic representation of Upadravas of Sthoulya 54 Title of Figure1 Showing causes of Obesity 222 Showing etiology of Obesity 51 Title of Photo1 Photography showing the Adeno-virus 362 Photography showing the ingredients of Mushkakadi Yoga3 Photography showing the Mushkakadi Yoga in granular form4 Photagraphy showing the Diagnosticinstrumrnts of Obesity x
    • Acknowledgement “Rome was not built in a day “, that’s a proverb most often said, heard andsometimes even ignored. But it holds true, as it was a result of a never lasting hardendeavor of thousands of hands, hearts and heads. Similarly, it is said that Shah –Jahan, built Taj Mahal but it was the sweat and blood of countless laborers thatstructured this antique monument. In the same manner, any research is never anindividual effort. It gives me inexpressible pleasure to thank all of those kind heartedhuman beings who have given me their unconditional support and guidance incompleting my thesis work. First of all I am highly obliged to my parents who have architected my career,right from school – life up to this level, just as God has architected this Universeflawlessly. I am also thankful to them for instilling a never – say – die spirit withinme. I also cannot forget my aunties, Smt.Purnima Sharma and Km.Sarla Sharma,for their constant encouragement and support, both morally and financially. I am alsograteful to my uncle, Late Dr.G.C.Sharma, who is no more with us . He has left forhis heavenly abode. His words, which encouraged me to go for Post – Graduation,still echoes in my ear. They were as follows – “To win silver, has just one simplemeaning, and that is, you have lost the gold “. May his soul rest in peace and continueto bless me in the pursuit of my mission of helping the society through my medicalknowledge I express my deep sense of gratification to my honorable H.O.D, Dr. K.S.R.Prasad, M.D (Ayu), H.O.D, P.G Department of Kayachikitsa, P.G.S & R.C,D.G.M.A.M.C, Gadag for his critical suggestions and expert guidance for thecompletion of this work. i
    • I am extremely happy to express my deepest sense of gratitude to my belovedGuide Dr. R.V.Shettar, M.D. (Ayu). Asst Professor, P.G. Department of Kayachikitsa,P.G.S & R.C, D.G.M.A.M.C, Gadag, whose unselfish guidance and sympatheticsuggestions inspired me not only to accomplish this work but in all aspects. I express my deep gratitude to Dr. G.B. Patil, Principal, D.G.M.A.M.C,Gadag, for his constant supervision, encouragement and wholehearted support duringmy research study. I am also thankful to him for providing all the necessary facilitiesneeded for this research work such as a good library, a well-equipped pharmacy and awell-managed laboratory. I express my sincere gratitude to Lecturer Dr. Mulkipatil, for his sincereadvices and assistance. I am deeply obliged to Dr. Kuber Sankh, M.D. (Ayu), Department of DravyaGuna, P.G.S& R.C. D.G.MA.M.C, Gadag for his constant encouragement andguidance at very step during my research work. I take this opportunity to thank H.OD’s of other departments Dr.M.C.Patil,M.D.(Ayu) , Dr. P.Shivaramadu M.D.(Ayu) and Dr. G.V.Mulgund , M.D.(Ayu) fortheir inspiration and valuable suggestions . I am grateful to all the P.G. Teachers Dr.Girish Dannappagouder M.D (Ayu),Dr Jagadesh. G. Mitti M.D (Ayu), Dr. Dilipkumar.B. M.D. (Ayu), Dr..ShashidharNidagundi M.D (Ayu) Dr. Santosh . N.Belavadi M.D (Ayu) and other P.G staff, fortheir valuable suggestions I extend my immense gratitude.to Dr.G.S.Hiremath, Dr. S.A.Patil,Dr.U.V.Purad,Dr.B.G.Swami, Dr.Paraddi, Dr.Sajjana, Dr.A.Samudri, Dr.Yasmin, Dr.Shankaragouda,Dr.G.Yarageri, Dr.S.H.Radder, and other teaching staff who helped during my study. ii
    • My sincere thanks are extended to Dr.Prakash, for his great support inpreparing my trial drug. I cannot move further before thanking my younger brother, Kamal Sharma,who not only encouraged me to accomplish my research work but was always ready togive me some time , out of his busy schedule , whenever I needed his help . I am highlyunder the debt of my brother who have helped me in all the moments during my PostGraduate Studies. I am greatly thankful to my intimate friends Devendra S.Chandeila, RahulMudgal, Devendra Solanki, Dr.Shivaprasad, Dr.Ashok, and Dr. Bhupesh who has stoodindefatigable with me in each and every circumstance and gave me in depth sense offriendship. I take this moment to express my sincere thanks to my seniors,Dr.Vijaykumarswamy, G.Hiramath, Dr.Sarvi, Dr.Kalmath, Dr.Ratan, Dr.Uday,Dr.Kumbhar, who were always there to help me out just like an elder brother, I am very much thankful to Librarian Shri V.M.Mundinamani, and AsstLibranian ShriS.B.Sureban and Shri Savi for providing valuable books in timethroughout the study. I would like to express my sincere thanks to Smt.P.K.Belavadi, Mr M.N.Joshi,Mr.Shankar, Mr.Biradar, Mr.Dasar and Smt.Sarangamath. John Murphy, Ex.Professor of Surgery North – Western University, Chicago,U.S.A. once rightly said that “ the patient is the centre of the medical universe aroundwhich all over works revolve and towards which all our efforts trend.” So, I cannotforget to thank the patients who are the pillars of my research work. I am also thankfullto the laboratory staff and Hospital staff and to all the persons who have helped medirectly or indirectly with apologies for my inability to identify individually. iii
    • Last but not least, I want to thank whole heartedly to my better half, i.e, my wife,Divya. Some support or help can never be reciprocated and such was her support andhelp throughout my research study. She was always there for tightening my screwswhenever I felt lethargic or for lifting up my spirits whenever I felt low. That charm onher face kept reminding me of my aim and helped me to accomplish my work. Though Iam thanking her, but I don’t think it stands anywhere near her help & support, becausethat was purely divine. Dr.Shekhar Shakti Sharma iv
    • Abstract: In Ayurveda, sthoulya has been considered as a Santarpanjanya vyadhi and asthoola person has been considered as one of the Ashtanindidhita purushas asmentioned by Charaka. A sthoola person lives a troublesome life as sthoulya can beconsidered the mother of various life threatening diseases like cardio-vascularproblems, hampered sexual activity (kruchhvyayavata), various respiratory disorderslike pulmonary embolism, pulmonary hypertension, etc.,other central nervousdisorders like stroke, idiopathic intracranial hypertension etc, malignant disorderssuch as endometrial, breast, gall bladder cancers and other endocrine, metabolicdisorders. Charaka has even described sthoulya as a disease that decreases the spanof life. Obesity is an upcoming problem, not only in developed countries but also inunderdeveloped and developing countries. Hence, the present study i.e. Evaluation ofefficacy of Mushkakadi Yoga in Sthoulya is undertaken to assess the effect of thestudy over sthoulya. The objectives of the study are to evaluate the efficacy of Mushkakadi Yoga insthoulya and evaluation of efficacy of MushkakadiYoga in hyper- cholostreamia.. Thestudy is a randomized clinical trial in a single group of 25 patients where all thepatients received “Mushkakadi Yoga” for 60 days with lukewarm water as itsanupana. The treatment was followed by the follow up of 30 days Subjective parameters are the chief and associated complaints of sthoulya.Objective parameters considered in the study are weight, BMI, chest, hip, abdominalcircumferences, hip-waist ratio, and height-weight ratio. Observations are donebefore the treatment, during the treatment, and after the treatment. v
    • Among 25 patients 4 patients (16%) have shown good response i.e.improvement of 70% or more in both subjective and objective parameters, 15 (60%)patients have shown moderate response, i.e., 50-70% in both subjective and objectiveparameters and 6 patients (24%) have shown mild response. Sthoulya being a Santarpanjanjanya vyadhi has Kapha as the predominantrasa as it is having Ashryaashrayisabhava with meda dhatu which is the mainsamprapti ghataka of the disease and the ingredients of Mushkakadi Yoga arehaving ushna, tikshna, lekhana, karshana etc. properties. vi
    • IntroductionIntroduction: Rudiments of the knowledge of medicine are traceable from Rig Vedaonwards, i.e. 10,000 years back. However its actual systemization and compilationcab be said to have commenced from the much later Samhita period of 7,000 yearsago. Science of medicine or Ayurveda actually means acknowledge of the span ofliving, its good maintenance, all round excellence and possible extension beyond theusual limit. It is thus much more than merely curing illness. This started as anUpaveda of Atharvaveda. Some authorities however trace it to Rig Veda as the laterCharana Vyuha text indicates. From time immemorial Ayurveda has given guidelines and will continue togive guidelines to mankind about the art of living, science of health and philosophy oflife. Ayurveda has studied man in relation to the Universe and has come to thescientific conclusion that man is the epitome of Universe. All objects in the Universeright from energy particles to high celestial bodies and from microbes to man arederived from the same basic elements. But in this modern era man is constantly distancing himself from the Nature.He is gaining wealth but loosing health. He wants to live a luxurious, sedentary lifestyle and is accustomized to improper dietary habits such as over eating andconsumption of high calorie and highly processed food stuffs. This leads toaccumulation of more and more fat in the body causing Sthoulya, which have graspedalmost one quarter of earth’s population. 1 Sthoulya is considered as a Santarpanajanya Vyadhi2 in Ayurveda and anAtisthoola purusha is considered to be one among the Asthanindita purushas3. According to modern science Overweight and Obesity are defined asabnormal or excessive fat accumulation that may impair health4. Obesity in 21st Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 1
    • Introductioncentury, is not less than any epidemic5 targeting more and more people each day,especially in developed countries, where approximately one in six adults are sufferingfrom obesity6 Body mass index (weight in cms/height in meter2) is a simple index, which iscommonly used in classifying overweight and obesity in adultpopulations andindividuals. The World Health Organization (WHO) defines “overweight”as a BMIequal to or more than 25 and “obesity” as a bmi equal to or more than 30. This cut-offprovides a benchmark for individual assessment, but there is evidence that risk ofchronic disease in population’s increases progressively from a BMI of 217.WHO’s a latest projection indicates that globally:• Approximately 1.6 billion adults (age 15+) are overweight• Approximately at least 400 million adults are obese8 WHO further projects that by 2015, approximately 2.3 billion adults will beoverweight and more than 700 million will be obese. At least 20 million childrenunder the age of 5 years are overweight globally. Once considered a problem only inhigh-income countries, overweight and obesity are now dramatically on the rise inlow- and – middle income countries, particularly in urban settings9. The fundamental cause of obesity is an energy imbalance between caloriesconsumed on one hand and calories expended on other hand. Global increase inobesity is attributable to a number of factors including:• A global shift in diet towards increased intake of energy –dense foods that arehigh in fat and sugars but low in vitamins, minerals and other micronutrients; and• A trend towards decreased physical activity due to the increasingly sedentarynature of many forms of work, changing modes of transportation and increasingurbanization10. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 2
    • IntroductionObesity leads to serious health consequences. Risk increases progressively as BMIincreases. Raised body mass index is major risk factor for chronic disease such asCardio-vascular disease, Diabetes, Muscular disorders, especially, osteoarthritis, andsome cancers (endometrial, breast and colon). Childhood obesity is associated with ahigher chance of pre-mature death and disability in adulthood11.Many low and middle-income countries are now facing a “double burden” ofdisease12: • While they continue to deal with the problems of infectious disease and under-nutrition, at the same time they are experiencing a rapid upsurge in chronic diseaserisk factors such as obesity and overweight, particularly in urban settings. • It is not uncommon to find under nutrition and obesity side by side within thesame country, the same community and even within the same household. • Inadequate pre-natal, infant causes this double burden and young childnutrition followed by exposure to high fat, energy-dense, micronutrient-poor foodsand lack of physical activity. Although, in modern science, there are many remedies practiced now a dayssuch as lipisection etc but they have complications and are also much expensive. Onthe other hand Ayurveda resists the Cartesian worldview of Allopathy, whichseparates mind and body and its advocacy of the mechanical intervention into naturethat strives to manufacture health. In Ayurveda, knowledge is context bound, resistant to universalizing rulesacceptable to all. A glance at historical records will be beneficial in drawingreferences and inferences regarding the development of any concept of knowledge.Hence, it is necessary to implement the chikitsa sutras mentioned by our acharyas inreducing the sthoulya. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 3
    • Introduction This clinical study is an attempt to evaluate the efficacy of Mushkakadi Yogain the management of Sthoulya. Samana causes increase and viprita causes decrease13,hence Sthoulya being a Santarpanajanya Vyadhi14 requires Apatarpana chikitsa15which can be achieved by Mushkakadi Yoga as all the constituent dravyas are ushnaand tikshna gunayukta having the properties of lekhana, karshana andhence possessthe quality of Medoghna16. This research work is a randomized single group clinical study with thesample size being 30 patients, minimum. Patients between 20-60 years of age, irrespective of sex and having 10%excess weight than the average weight in relation to height and having all clinicalsigns and symptoms of Sthoulya are included in the clinical study while patients withsecondary pathologies like Diabetes Mellitus etc. or those having obesity associatedwith hormonal disturbance or those having obesity associated with other systemicdisorders are excluded from the clinical study. Stagnancy is the first sign of future crumbling; hence one should always becraving for some new remedy for a disease. Keeping this trend in mind this clinicalstudy is a humble attempt to evaluate the efficacy of Mushkakadi Yoga in themanagement of Sthoulya. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 4
    • ObjectivesObjecives: • In this modern era the gap between man and Nature is increasing constantly .He is gaining wealth but loosing health. He wants to live a luxorious, sedentary life style and is accustomized to improper dietary habits such as over – eating and consumption of high calorie and highly processed foodstuffs. This leads to accumulation of more fat in the body. • By seeing the pathology of Sthoulya it seems to be some as Obesity of modern science. • Obesity in 21st century is not less than any epidemic targeting more and more people each day, especially in developed countries, where approximately one in six adults are suffering from obesity. • Once considered a problem only in high-income countries, overweight and obesity are now dramatically on the rise in the low-and-middle income countries, particularly in urban settings17. • The major risk related with Sthoulya is that, it favours complicated pathologies like Prameha, Kustha, Shwasa, Kasa, Vatavyadhi, etc. and it is a well established fact that, obesity invites life threatening complications like cardiomyopathy, cardiac arrythmias, ahtherosclerosis, stroke, hypoventilation syndrome, chronic bronchitis, pulmonary embolism, gall stones, cholecystitis, pancreatitis, idiopathic intracranial hypertension and carcinanas of prostate, gall bladder, breast colan etc. Thus, obesity if not checked at proper stage and time, will reduce the life expectancy and contribute to the increasing morbidity and mortality rate. So it is widely said, “Longer the size of the belt, Shorter is the span of life.” Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 5
    • Objectives • Atisthoula purusha has been considered as one among the asthanindita purusha18 and it has been stated that Sthoolasya Na hi bhesajam. But it is the demand of the time to treat him rationally with multidimensional approach, so that life expectancy can be hiked and he can be prevented from dreadful diseases. • In contemporary medicine the treatment modalities like some appetite suppressants and other surgical modalities are explained in the management of obesity19. Amphetamine is used more less than often. It suppresses hunger as a result ofinhibition of hypothalamic feeding centre. But it has a limited scope and it is shortlived and may be accompanied by anxiety, restlessness, tremor, and dysphoria. Andagitation and above all it is contraindicated in coronary heart diseases, HTN etc20.Second drug used is Fenfluramine, which reduces food-seeking behavior as well asdecreases quantity of food consumed at any meal, by enhancing serotoninergictransmission in the hypothalamus. But it has severd-associated side effects likelethargy, drowsiness, loss of libido, dry mouth and diarrhea21. Another drug used isSibutramine but it is contraindicated in patients with a history of hypertension,coronary artery disease, and congestivewe heart failure, Arrhythmias. The surgicaltherapies adopted for the management of obesity are also associated with manycomplications. • Considering the hazards associated with obesity and the complications arising from the use of drugs available in contemporary medicine, it becomes essential to search for something within Ayurveda, that could prove to be a more effective remedy in the management of Sthoulya (obesity). The major line of treatment for Sthoulya, as given by Acharya Charaka, is Guru cha Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 6
    • Objectives Apatarpana22. Other principles on which the treatment of Sthoulya is based are Vataghna, Sleshmomedoharana, Rookshana and Sadhana23. Guru Cha Apatarpana Vataghna, Sleshmomedoharana in the form of annapana is the major treatment of Sthoulya and keeping this concept in mind, present study is an attempt to fund suitable remedy for Sthoulya as mentioned specially by Sushruta, i.e. Mushkakadi Yoga24 is taken and hypothetically the following objectives are evaluated – • Evaluation of efficacy of Mushkakadi Yoga in Sthoulya • Evaluation of efficacy of Mushkakadi Yoga in hyper-cholesteremia 1. Evaluation of efficacy of Mushkakadi Yoga in Sthoulya Sthoulya is considered as a kapliananatmaja vikara as well as a Meda dhatudushti vikara. In Sthoulya, due to consumption of Kapha vardhaka Aharavihara, Medadhatu increases (being of similar as of kapha) which in turn leads to srotorodha( Obstruction of the channels). This leads to under / un nourishment of the Uttar Dhatusand also leads to prakopa of Kosthagata vayu (samana vayu) which in turn causes atisandukshan of the pachakagni leading to quick digestion of food and this in turnincreases the craving for more food and thus accumulation of more fat and henceSthoulya. As Sthoulya is caused by taking Kaphakara ahara viharas and it is medodoshajavyadhi. Kapha and meda are having ashryashrayi bhava and in the samprapti vata isalso one of the pathological entities. So it is necessary to subside both kapha and vata. In Mushkakadi Yoga almost all the constituent dravayas are having theproperties of ushna, teekshna guna pradhana and lekhana, karshana, which may provehandfull in checking the Sampraptiof Sthoulya. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 7
    • Objectives2. Evaluation of efficacy of Mushkakadi Yoga in hyper – cholestremia: Cholesterol is present in the diet of all people and it can be absorbed slowlyfrom the gastrointestinal tract into the intestinal lymph. It is highly fat soluble but onlyslightly soluble in water and is capable of forming esters with fatty – acids. A highly saturated fat diet increases the blood cholesterol concentrationwhereas ingestion of fat containing unsaturated fatty acids usually depresses the bloodcholesterol concentration. Lack of insulin or thyroid hormone also increases the bloodcholesterol concentration. Values of plasma lipids in healthy adults depend on the pattern of diet. Thuspersons following high quantities of animal fats (which contains saturated fatty acidsonly), tend to have high plasma lipid values, particularly high values of plasmacholesterol, on the other hand, persons taking rice, vegetables and high amount of polyunsaturated fatty acid have low plasma lipid values particularly plasma cholesterol. Removal of Lipids occurs through: • Deposition of fat in the depots • Oxidation of fat in the tissue • Utilization for formation of tissue structure formation. The constituent dravyas of Mushkakadi Yoga are ushna, tikshna guna pradhanaand have the properties of lekhana and karshana and hence can reduce the deposition ofmeda and in turn this Mushkakadi Yoga may check the pathology of Sthoulya. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 8
    • Historical reviewHistorical aspect of Sthoulya: History is the mirror, which does not show what you are but reflects what youwere. Hence, a glance at historical records will be beneficial in drawing thereferences and inferences regarding the development of any concept of knowledge.History about sthoulya can be reviewed as following,VEDA KALA (1000-500BC): Vedas, which are considered as the treatise of knowledge and are known as thedawn of science, are the first source of medical science. Though, detail descriptionregarding sthoulya is not available, some scattered references are available they arelisted below, • In Rigveda25 the words Meda and Vasa are mentioned. • In Yajurveda26, there is mention of a disease named Upachita. • In Atharva Veda words like medina27, pivasi28, and medas29 are available for Sthoulya. It has been advised to strengthen and harden the body like a stone, i.e. expressed the hazards of flabbiness of the body and Sthoulya30.SAMHITA KALA (200 BC – 400 AD)Charaka Samhita (2 B.C.) - No one can be audacious enough to dony the superiority of charaka in the fieldof medicine. He has described Sthoulya in Sutrasthana. He has considered Sthoulya asSleshma Nanatmaja Vikara31, Santarpana Nimmitaja Vikara32 and AdhikadoshayuktaRoga33. The entire nidana- Panchaka of Sthoulya has been described by charaka in the21st chapter of Sutrasthama. Evaluaion of Efficacy of Mushkakadi Yoga in Sthoulya 9
    • Historical reviewSushruta Samhita (2 A.D.) If Charaka is considered the master of medicine, Madhavakar the sole behindNidana (aetiology) and Vaghbhatta the best about sutrasthama, then Sushruta’ssupremacy can never be challenged in the field of surgery. Sushruta has descriptely described the nidana < aetiology >, poorvaroopa(Prognosis) Samprapti (pathogenesis), roopa (signs) etc. of Sthoulya34 as RasaNimittaja Vyadhi35 and considered Meda vtiation as the etiological factor36. Heprovides a new name for Sthoulya, i.e. Jatharya37.Asthanga Sangraha (6 A.D)., Asthanga Hridya (6 A.D). Sthoulya is considered as a disorder of Sleshmadosha seated inMedodhatu38.Not only the classification and management of Sthoulya39 but also thepathogenesis and symptoms of it are clearly mentioned40. A new synonym Sthavimais explained for Sthoulya41.Kashyapa Samhita: (6 A.D) Rakta mokshana especially Siravedha is indicated for the medhasvidhrati42.Sthoulya is considered as one among the asthanindita purusha while explaining theanthropology43.Bhela Samhita (7 A.D.) - In Bhela Samhita Sthoulya is described as a disorder of vitiated Meda44.Madhava Nidana (7 A.D.)- Madhavakar has elaborated the path physiology of this disease based on fattissue and fat depot site45 .The clear symptomatology of Sthoulya including someadditional symptom like moha, has been elaborated46.Sharangadhara Samhita (13th century) Evaluaion of Efficacy of Mushkakadi Yoga in Sthoulya 10
    • Historical review He has considered vitiation of Vata as a cause of Medodosha47. Undoubtedlyhe can be considered as the first person that has described the role of vrikka (renal &suprarenal glands) in the nourishment of Jatharastha meda and omentum.48Samgraha Kala & CommentatorsChakrapani (11th century) - In line of treatment of Sthoulya he has commented that guru and Aptarpanaproperty helps to alleviate Kshudha and reduce Meda respectively49.Dalhana (12th century) Explains regarding Ama formation in tikshoagni. Regarding line of treatmenthe has Interpreted Virukshana as medoghna and chedaniya as strota vishodana50.Indu (13th century) He has given explanation of Saktu, Loha etc words used in the management ofSthoulya51.Arunadutta (13th century) The word “sthawima” has been used for the sthoulya, explained on the basis ofetymology in sarvanga sundari commentary in Astanga Hridya52.Hemadri (13th century) He had advised to take choorna of Yavani, Madukajalam as Madhu mishritaudaka Dandahata as Takra, Agnimantha as Tarkari, Kshara as Yavakshara, as themanagement of sthoulya in his Ayurveda Rasayana commentary on AstangaHridaya53.Adamalla (14th century) & Kashiram (17th century ) Adamalla described Sarakthameda as the one, which is lodged in the sthulasthiinner to the majja54. Kashiram has described medoroga as a Vata pradhana Vyadhi inhis classic text, titled, Gudartha deepika55. Evaluaion of Efficacy of Mushkakadi Yoga in Sthoulya 11
    • Historical reviewVangasena (12th century) In Medorogadhikara, he has explained the nidana – panchaka along withchikitsa of Sthoulya56.Bhava Prakasha (16th century) In chapter No. 39, named Sthoulyadhikara57, he has described nidana(aetiology),Lakshana (signs and symptoms)and upadrava (complications)of Sthoulya.Yogaratnakara (17th century) There is description of Sthoulya in Yogaratnakara Uttarada’s MedoroganidanaAdhyaya. Various herbomineral preparations have been prescribed in the managementof Sthoulya58.Review of previous work:Number of research works on the management of sthoulya has been done previously. • Anti Cholesterolaenic effect of fenugreek < methi > by Chakravarti .S. And Mitra .S. Dept of Home Science, Calcutta submitted in national conference Conducted on 2-4April 1998. • Effect of barley-rice-feeding <boiled>in hypercholesterinic and Normolipidaemic by Ikegami .S, Tomita. M., Honda. S., Yamaguchin, Muzukajya from National Institute of Health and Nutrition. Suinjuko , Tokio Published in plant foods for human nutrition , Volume – 49 , p.No. – 317-328, 1996. • Medodhatvagni Ka Sthoulya Roga Ke Sandarbha mein Saindhantika Evam Prayogika Adhyayan, by Vasudeva, Department of Basic Principles, Jamnagar, 2001. Evaluaion of Efficacy of Mushkakadi Yoga in Sthoulya 12
    • Historical review• The role of certain Ayurvedic anorexiant drugs in the management of Sthoulya (obesity) by Pandya Amrish (Ph.D) Department of Kayachikitsa, Jamnagar, 1999.• A clinical study on the management of Sthoulya (obesity) byPanchtikta and Lekhana Vasti by Rekha Savajani , Department of Kayachikitsa , Jamnagar , 2001• Aetiopathological study of Sthoulya (obesity) and assessment of the effect of The Devadarvyadi Vati and virechana karma, by Sarika Mehta, Department of Kayachikitsa, Jamnagar, 2003.• A comprehensive study of “Chakraniarda “with special reference to “Sthoulya” By Zala Jyotsanaba, Department of Dravyaguna, Jamnagar, 1998.• A comprehensive study on Madhu & his role in the management of Medoroga, by Charushila Giri, Department of Dravyaguna. Jamnagar, 2000.• An assessment of activites of Rukshna guna with special reference to “Sthoulya” by Anand Buchake, Department of Dravyaguna, Jamnagar, 2002.• A comparative pharmaceutico – clinical study on Shilajeet (Triphala Sodhita and Gomutra Sodhita)and its effect on Medoroga, by Jagdev S.R., Department of Rasashastra and Bhaisajya, Jamnagar, 2002.• A Pharmaceutico - Pharmaco clinical study on guggulu with special reference to its medohara effect, by Rajput Anurag Singh, Department of Rasashastra and Bhaisajya, Jamnagar, 2003.• Conceptual and clinical study of “Sthoulya Roga” and its management with a Selected indigenous compound, by Shah Hema A, Govt. Ayurveda College, Department of Kayachikitsa, Ahmedabad, 1998. Evaluaion of Efficacy of Mushkakadi Yoga in Sthoulya 13
    • Historical review• Comparative study of Lekhana therapies in the management of Sthoulya, by Ananda Prasad Nayak, Govt. Ayurveda College, Department of Kayachikitsa, Ahmedabad, 2003.• Study on inters – relationship between Medoroga and Prameha, by Priyadarshini, Banaras Hindu University, Department of Kayachikitsa, Varanasi, 1999.• A clinical study of Medoroga (obesity) with herbomineral compound, by Roy Krishna, Department of Kayachikitsa, Calcutta, 1999.• Clinical evaluation of Bala Haritaki on serum cholesterol, by Sood Rajiv, Department of Kayachikitsa, Jaipur, 1999.• Sthoulya vyadhi par Navayas Koha Ka parinam – Ek Adhyayan, by Pathan S.K. Department of Kayachikitsa, Nanded, 1998.• Amrutadi guggulu nirman Evam uske medovah karna ka aturalayin adhyayan, by Kanholkar N.T., Department of Kayachikitsa, Nagpur, 2000.• To study the efficacy of the Lekhan Vasti in Sthoulya, by SabdeM.S. Department of Panchakarma, Pune, 1999.• The study of Lukewarmwater (Koshna Jala) on obesity, by Velhal A.R., Department of Swasthvritta, Pune, 2000. Evaluaion of Efficacy of Mushkakadi Yoga in Sthoulya 14
    • Historical reviewVyutpatti and Nirukti of SthoulyaVyutpatti: The word sthoulya derives its name from root “Sthu” with suffix “Ach”.The literal meaning of the term is any bulky, solid or weighing substance59.Nirukti60: Sthoulya refers to the existence of Sthoulyatva, i.e., bulkiness, as describedin Sabdakalpadruma. • Durgadas described Sthoola person as one with increase Bruhanatva. • Sthoola, literally, means something large, great, bulky, huge, fat, corpulent etc61.Paribhasa: A person having pendulous appearance of sphika,udara and stana due toexcess deposition of meda along with mamsa dhatu and also having unequal andabnormal distribution of meda with reduced zeal towards life is called Atisthoola62.Paryaya: Pinam, Pivara, Pivaram, Sthoola, Pina, Piva, Pivam, Pivasa, Pivistha, Medana,Medini, Medasvina63.Etymology of word obesity: The word obesity is a noun form originated from the Greek root word“Obesus” meaning “having eaten until fat”, Latin “Edo” meaning “eat” is used as anadjective meaning “grossly fat” or “very fat”64.Definition: “Overweight” and “Obesity” are terms commonly used to describe individualswith increased body fat. Obesity has been described as an increase in body weight Evaluaion of Efficacy of Mushkakadi Yoga in Sthoulya 15
    • Historical reviewbeyond the limitation of skeletal and physical requirements, as the result of excessiveaccumulation of body fat65. An abnormal growth of adipose tissue due to an enlargement of fat cell size(hypertrophic obesity) or an increase in number of fat cells (hyperplastic obesity) oran combination of both. (K.Park). 66. Obesity is defined as an excess of body fat that possess a health risk It isconsidered as the abnormal amount of fat in the body67. Obesity is defined as anexcess of body fat that possess a health risk68. Modern science69 and Ayurveda70 evenconsiders obesity as a result of familial and genetic predisposition. Observing theabove description and terminologies, we can compare the disease Sthoulya withObesity.Synonyms: Adiposity,Corpulence,Overweight, fatty, Turgidity, Hypertrophy, Stoutness,Enormity, Polysaraca, oily dropsy, Plumpness, Embonpoint. Evaluaion of Efficacy of Mushkakadi Yoga in Sthoulya 16
    • Disease reviewNidana of Sthoulya: Without the proper diagnosis of disease, no physician can provide anappropriate treatment of it. That’s why to have a proper knowledge regarding anyvyadhi the role of nidana panchaka is very essential. Nidana (etiological factors) provides vital information not only regarding thediagnosis of a disease but also about its pathological entities as well as the chikitsa ashas been described by Sushruta. The knowledge of nidana not only aids the physiciantowards therapeutics but also in advising about pathyaapathya. The components ofmeda and sleshma vitiation are said to be responsible for stholya. Charaka hasmentioned the exogenous causes while Sushruta and Vagbhatta has mentioned theendogenous causes of Stholya. Exogenous causes pertains to the diets that has thepotential of increasing the meda or body fat where as Dosha, Dhatu, Mala, Srotas etccomes under endogenous causes. Exclusively Charaka has also consideredBeejadosha as a cause of Sthoulyad71.In sort, nidana of Sthoulya can be categorized as follows- • Aharaja nidana • Viharaja nidana • BeejadoshajaRole of Aharaja nidana:- Role of Ahara rasa is very important in deciding the pramana of meda dhatu inthe body. Sushruta in Sutrasthana has highlighted this fact by quoting that “thequantity and quality of ahara rasa in the shareera is responsible for sthoolta orkarshyta”72. The qualities of ahara rasa that will increase kapha and meda will lead toSthoulya, viz. Rasa - Madhura Evaluation of Efficacy of Mushkakadi Yoga 17
    • Disease review Guna – guru, sheeta, manda, snigdha, slakshna Virya – sheeta Vipaka – madhura Mahabhuta – prithvi& aapa.. Guru & snigdha ahara: -Guru and Snigdha are the properties of Meda orbody fat. Meda and sleshma enjoys Ashryashryaee relation, meda being the ashrya ofsleshma73 .Hence the sleshmala ahara (guru& snigdha) is going to increase meda alsonot only because of Ashryashryaee bhava but also because of Samanya vriddhikaranam concept given by Charaka. Madhura Rasa Sevana; - Not only Charaka, Sushruta, Vagbhatta but otheracharyas such as Yogratnakara, Bhavmishra have considered Madhura rasa as anetiological factor for Sthoulya74. Madhura rasa and Meda, both share the same Mahabhuta composition i.e.,Prithvi + Jala. Hence consumption of madhura rasa pradhana dravyas such as Ikshuvikaras (sugars), carbohydrates, sweet fruits etc. are going to increase Meda, which inturn will lead to Sthoulya. Mamsa sevana: - Kashyapa has mentioned mamsa as the best diet for growthof muscles and body fat75. Charaka has given special reference of anoopa deshajamamsa like Srumara (forest pig), Mahisha, Gavaya, Gaja, etc (Cha. Su.27/56-57)which have the qualities of kapha and are going to increase meda on the basis of gunakarma sadharmya concept, thus leading to stholya. Madya sevana; - Charaka has mentioned madya sevana and that too navmadya which is guru and kaphavardhak as one of the factors responsible forMedovaha Strota dushti that can lead to meda vriddi and hence stholya76. Evaluation of Efficacy of Mushkakadi Yoga 18
    • Disease review Gorasa, dadhi atisevana: - Gorasa includes all the secondary products ofmilk like dadhi navneeta gritha etc., which are homogeneous to kapha & meda dhatuexcess intake of these leads to sthoulya. Ahara krama: - Acharyas have mentioned factors like Adhyashana andAtisampooranad in the nidana of stholya. Bhojanottar Jalapana has been considered as the causative factor for amaformation by Kashyapa and hence becomes a cause for stholya77Role of viharaja nidana: - Avyayama: - Metabolism refers to the sum of all the physical and chemicalprocesses taking place within an organism. It includes both anabolism andcatabolism. A proper balance between the two is essential for a healthy life. Catabolicactivity is low in a person living luxuriously with sedentary life style and notindulging in physical exercise and so there is more tendency of accumulation ofkapha & meda in the body of these people & this leads to sthoulya. Diwaswapna & atinidra.: - Diwaswapna has been considered by all acharyasas a kapha prakopaka hetu and a santarpaka hetu. It increases the abhishyandi gunadue to which there is srotorodha (obstruction of the srotas) that ultimately leads tosthoulya in due course of time.Role of manasika nidana: - Achintana, Harshanitya, Manasonivritti have beenconsidered as the manasika nidanas of sthoulya in Ayurveda78.Beejaswabhavaja: - Acharya Charaka has specifically mentioned Beejadosha as thenidana for sthoulya & Chakrapani comments over it as “ati sthula mata pitru sonithasukra swabhavat”.These can be compiled as below, Evaluation of Efficacy of Mushkakadi Yoga 19
    • Disease review Table No: 01. Showing Aharaja Nidana (79, 80, 81, 82, 83, 84, 85)Sr No. Aharaja Nidana CH SU AS AH MN BP YR1 Atisampurna + _ _ _ _ _ _2 Santarpana + _ + + _ _ _3 Adhyasana _ + _ _ _ _ _4 Guru ahara sevana + _ _ _ _ _ _5 Madhura ahara sevana + _ _ _ _ _ _6 Sheeta ahara sevana + _ _ _ _ _ _7 Snigdha ahara sevana + _ + + + _ +8 Sleshmala ahara sevan + + _ _ + + +9 Navanna sesana + _ _ _ _ _ _10 Navamadya sevana + _ _ _ _ _ _11 Gramya Rasa Sevana + _ _ _ _ _ _12 Mamsa sevana + _ _ _ _ _ _13 Paya vikara sevana + _ + + _ _ _14 Dadhi sevana + _ _ _ _ _ _15 Sarpi sevana + _ _ + _ _ _16 Ikshu vikara sevana + _ _ + _ _ _17 Guda vikara sevana + _ _ _ _ _ _18 Shali sevana + _ _ _ _ _ _19 Godhuma sevana + _ _ _ _ _ _20 Masha sevana + _ _ _ _ _ _21 Rasayana sevana + _ _ _ _ _ _22 Vrishya sevana + _ _ _ _ _ _23 Bhojanottara Jala pana _ _ + _ _ + + Evaluation of Efficacy of Mushkakadi Yoga 20
    • Disease review Table No 02: Showing the Viharaja NidanaSr No Viharaja Nidana CH SU AS AH MN BP YR1 Avyayam + + + _ + + +2 Avyavaya + _ + _ _ _ _3 Diva Swapna + + + _ + + +4 Asana Sukha + _ + + _ _ _5 Swapnaprasangat + _ + + _ _ _6 Gandhamalyanu Sevana + _ _ _ _ _ _7 Bhojanottara snana + _ _ _ _ _ _8 Bhojonottar Nidra _ _ _ _ _ + +9 BhojanottarAushadiSevana _ _ + _ _ _ _ Table No03: Showing the Manasika NidanaSr No Manasika Nidana CH SU AS AH MN BP YR1 Harshanityatvat + _ + + _ _ _2 Achintanat + _ + + _ _ _3 Manasonivritti + _ + + _ _ _4 Priyadarshana + _ _ _ _ _ _5 Saukhenya _ _ _ + _ _ _ Table No 04: Showing Anya NidanaSr No Anya Nidana CH SU AS AH MN BP YR1 Ama rasa _ + _ _ _ + _2 Snigdha Madhura + _ + + _ - _ Vasti Sevana3 Tailabhyanga + _ + + _ - _4 Snigdha Udvartana + _ _ _ _ - _5 Beejadoshasvabhavat + _ _ _ _ _ _ Evaluation of Efficacy of Mushkakadi Yoga 21
    • Disease reviewAetiology of obesity: - Modern science considers obesity as a state of increased bodyweight due to adipose tissue accumulation and classifies the etiology of obesity inthree groups viz. Fig No 01: Showing causes of obesity CAUSESEXOGENOUS ENDOGENOUS MISCELLANEOUSOver eating AgeDieting habits Endocrine factors SexDrinking habits OccupationSmoking Socioeconomic status Psychogenic factors Environmental factors Drugs Hypothalamic factors Physical activity Caloric BalanceDietary Factors: 86 Obesity in 21st century is not less than any epidemic. Obesity results fromexcessive intake of food, a modest but persistent excess intake of 50K cal/day willresult over a 4-year period in a slow but progressive rise in weight of 10kg. If thebalance between the consumption of food and expenditure is disturbed either due tolack of exercise or due to intake of excessive food, then weight will rise continue. Anextra gain of 10kg of weight indicates an about 70,000 stored Kcal. This storage Evaluation of Efficacy of Mushkakadi Yoga 22
    • Disease reviewpotential explains why it takes so long to loose weight. Weight gain is due toimbalance in energy intake & energy expenditure.Endocrine Factors87 Not only in normal physiology but also in pathological conditions theinfluence of endocrine factors on body fat can be observed. Obesity in womencommonly begins at puberty, during pregnancy or at the menopause suggesting anendocrine factor. Obesity frequently accompanies with, • Hypothalamic disorders – injury to the ventriomedial region of hypothalamus results in obesity. • Hypothyroidism – this condition lowers the energy requirements by lowering the BMR & physical activity. • Cushing’s syndrome –If there is excess secretion of ACTH from the pituitary it results in hyperplasia of adrenal glands and in this condition there is accumulation of fat in the trunk, suprascapular fossa & dorsal cervical region will be seen. • Polycystic ovary syndrome – In this condition there is excessive production of androgens from the ovary and irregular or absence of menses, hirutism, obesity &infertility characterizes it. • Hypogonadism : It is also associated with nextra fat deposits , particularly in breasts, abdomen ,hips and thighs &it seems possible that the obesity associated with mild degrees of hypopitutarism may be accounted for by the resulting combination of hypothyroidism & gonadismMiscellaneous factors: Age & sex: - Middle aged persons are more prone to be obese as gender andage both affects the body fat distribution. Both in men and women body fat increases Evaluation of Efficacy of Mushkakadi Yoga 23
    • Disease reviewwith the age. In lean young man, body fats less than 20% & may rise in older men tomore than 25%. In young women, body fat stores may be 30% & increase graduallyto more than 35& in older women. At all ages after puberty women are fatter thanmen. Over half of Americans between 20 and 75 years of age are overweight.88 Socio-economic status: - Obesity is considered as a rich man’s disease as it ismore prevalent in upper socioeconomic groups. But obesity may occur in any class ofsociety due to over eating & sedentary life style. Smoking: Giving up of smoking induces a fall in energy expenditure equalamount to 9Kcal/cigarette & increase in food intake. The average weight gain is2.8kg in males & 3.8kg in females. Nevertheless, the risk of smoking is so substantialthat a rise in weight of 1kg would be required to negate the benefit of giving up ofsmoking 20cigarettes/day89. Alcohol: - Alcohol provides substantial energy & can stimulate appetite &loosens restraint and hence promotes weight gain90. Urbanization: - In urban people energy intake is more than energy output asthey are restrict themselves from strenuous physical exercise and consume dry foodsmade up of fat and sugar. Influence of Drugs91, 92: - In modern medicine, several drugs are found to becreating obesity, which are as follows, • Oral contraceptives • Glucocorticoids • Medroxy progesterone • Cyproheptadine • Lithium • Pleothiazines Evaluation of Efficacy of Mushkakadi Yoga 24
    • Disease review • Antiepileptics-Valporate, Carbamezepine • Antihypertensives-terazosin etcGenetic history: - Genetic determinates can play a major role in the pathogenesis of obesity. Thedimorphic forms of human obesity in which genetics play a major role include theconditions, such as Prodder Willi syndrome, Ahlstromes syndrome, the Lourence-Moon-BIELD93 syndrome, Coher’s syndrome & Carpenter’s syndrome. The leptingene, which produces a syndrome complex, associated with obesity have implicatedover 20 genes on at least 12 chromosomes emphasizing the polygenic influence onthe development of obesity.Overall, the genetic contribution to weight gain in susceptible families ranges from25%-40%, with the genetic determination of selective intra-abdominal fat depositionbeing greater at 30%-50%94.Role of Psychological factors: - A Role of Psychological factor in creating obesity is worldly recognized butspecific type of mentality in association with it is yet to be achieved. According toBruch obesity is of two types one is reactive, another is developmental.Reactive obesity is a resultant of overeating as an emotional reaction to theenvironmental situation. Developmental obesity is also known as obese traitdepression. Ingestion of food has been frequently used to reduce the feelings ofemotional deprivation present since childhood. The literature on the psychology related to obesity is diverse, inventive andechectic. Individual at risk for developing obesity appear to have a lower thresholdfor psychological arousal than other people. Some studies show that acute hyper Evaluation of Efficacy of Mushkakadi Yoga 25
    • Disease reviewinsulineamia can be produced in some people by looking at or thinking about food,lead to increased consumption and possibly weight gain. Lissual and Rensen (1994) reported that parental neglect could greatlyincrease the risk of obesity. Dirty and neglected children have a greater risk of obesityat an adult age than averagely grown children.Classification of Sthoulya: A disease needs to be classified as per its severity and chronicity as it helps inthe diagnosis, prognosis and easy management of the disease. No such clearclassification of Sthoulya is mentioned in our classics. Only some of the Ayurvedicclassics like Astanga sangrha, Astanga Hridaya95 and Sharangadhar samhita havethrown some light on the classification of of the disease Sthoulya.While narrating the indications for langhana upkrama Astanga sangraha(A.S.Su.24/13-16) and Astanga hridaya have classified as, • Hina sthoulya • Madhyama sthoulya • Adhika stholyaSharangadara, on the basis of vitiation of meda and dominance of vata, has mentionedonly one type of sthoulya96 i.e. • Medo doshaAll other acharyas have mentioned only one type of sthoulya.Classification of obesity: - Obesity is classified on the different basis like onset, severity of the disease,histopathology and fat distribution etc. that are mentioned as below,According to the onset 1. Insidious 2. Gradual 3.Rapid Evaluation of Efficacy of Mushkakadi Yoga 26
    • Disease reviewAccording to severity 1. Mild 2. Moderate 3.SevereOn the basis of BMI97 • Overweight- 25 – 29.9 Kg/m2 • Obesity (class-I) 30 – 34.9 Kg/m2 • Obesity (class-II) 35 – 39.9 Kg/m2 • Severe or morbid obesity (class-III) > 40 Kg/m2According to Etiological factors • Physiological: Observed temporarily during puberty, pregnancy and lactation. • Pathological: It can be further divided into three – 1) Exogenous 2) Endogenous 3) IdiopathicOn the basis of Fat distribution98, 99: • Generalized: Generalized obesity is usually seen in exogenous obesity. • Central or Trunk type: Involving only the trunk and neck, it is common in Cushing’s syndrome or hypothyroidism. • Superior or Buffalo type: Involving the face, neck, arm and upper part of trunk and is common in Cushing’s syndrome or hypothyroidism. • Inferior lypodystrophy: Involving the lower part of the trunk and legs. Accompanied by wasting of upper half of the body. • Girdle type or fatty apron: Involving the hips, buttocks and abdomen found in pituitary or hypothalamic lesions. Evaluation of Efficacy of Mushkakadi Yoga 27
    • Disease review • Breeches or trochanteric type: Involving only the buttocks found in hypogonadal syndrome. • Lipomatous or multiple lipomatous: It is characterized by localized deposits of fat over the body called Dercum’s disease or adiposis dolorosa and is associated with tenderness and pain over the fatty lumps. • Android or Abdominal or Male obesity: Android obesity refers to the accumulation of body fat in abdominal region commonly found in men it has been considered as high risk form of obesity. • Gynoid or gluteofemoral or female obesity: Gynoid obesity refers to the accumulation of body fat in gluteofemoral region commonly found in pre menopausal women.On the basis of histopathology100: • Hyper plastic obesity – It refers to increase in adiposity’s number, i.e., number of fat cells. There is a life long history and the prognosis is bad. • Hypertrphic obesity – It refers to increase in adiposity size, i.e., increase in size of fat cells. There is history of adult onset and the prognosis is good. Viral Obesity: If obesity seems to be spreading like a virus, that could be because it is101.Another biological link to obesity may be the viruses and pathogens that makes yousick. A new field of research, called infect obesity, theorizes that certain commonviruses actually makes you fat. Evaluation of Efficacy of Mushkakadi Yoga 28
    • Disease review Researchers first noticed this phenomenon in animals. They found thatchickens, infected by a virus were obese and most of the fat was concentrated aroundthe stomach. Doctors hypothesized that human beings might react to viral infectionsthe same way – by storing excess fat. To test this theory, scientists screened human subjects for the existence ofantibodies to a common virus. Our body produces antibodies in response to a specificforeign substance, like a virus or bacteria. If antibodies are present, they indicate thatthe virus has infected the concerned person at some time and the antibodies oncedeveloped never go away. Doctors tested a random group of both obese and normal weight people. Theresulting data showed that 30% of the obese subjects had antibodies to the virus,while only 11% of the normal weight subjects had the antibodies. This significantdifference indicates that certain viral infections may directly contribute to obesity. Later, in 2000, researchers at the University of Wisconsin in Madison found outthat mice and chickens infected with a common human virus put on much more fatthan uninfected animals. They also discovered that the same virus is more prevalentamong overweight people, a strong indication that it may also cause obesity inhumans102. In four experiments, the Wisconsin researchers inoculated chickens andmice with adenovirus-36, a member of a viral family that includes about 50 strains.Most adenoviruses cause cold, diarrhoea, pinkeye. After several months, animalsinfected with adenovirus-36 weighed only 7 % more on average than those withoutthe virus, but their bodies contained more than twice as much fat103. Thus adenovirus-36 became the first human virus that was proved to cause obesity in animals and itwas also the first virus that researchers looked at, raising the possibility that other Evaluation of Efficacy of Mushkakadi Yoga 29
    • Disease reviewhuman viruses may also cause obesity. The researchers picked adenovirus-36 simplybecause little is known about it and the strain is relatively easy to work with104. Thisstudy was published in the August 2000 issue of the International Journal of Obesity.These studies do not indicate that viruses cause all obesity but they strongly suggestthat infection plays an important role. Unpublished studies in humans show that 20-30% of overweight people areinfected with adenovirus-36, compared to about 5% of the lean population. In the lastfew years, not only obesity but many other chronic diseases have been found to becaused by infections such as clogged arteries by three different microbes and ulcerscaused by the bacterium Helicobacter pylori105. But still after this experimental study researchers were unaware of thepathogenesis of viral obesity. Infected animals did not eat more than uninfected ones,suggesting that the virus decreases the energy expenditure rather than increasingappetite106. The animal obesity viruses appear to work differently from adenovirus-36, bydamaging the part of brain that controls appetite. The Wisconsin researchers saw nobrain damage in chickens and mice infected with adenovirus-36. Aside from a day ortwo of cold-like symptoms, the virus produced no observable effects besides obesity.Paradoxically, animals infected with the virus also have decreased levels ofcholesterol and triglycerides in their blood. Generally, obesity is associated with highcholesterol and triglyceride levels107. Last year Nikhil Dhurandhar at Louisiana State University at Baton Rougecarried out research work to understand how adenovirus-36 (Ad-36) causes fat cellsto grow. The conclusion of the research was that Ad-36 causes precursor cells todifferentiate into fat cells, and could promote obesity in humans and animals. Now he Evaluation of Efficacy of Mushkakadi Yoga 30
    • Disease reviewhas shown that a single viral gene is responsible for triggering this process, meaningthat one day it may be possible to treat “viral obesity” by altering the action of thatgene108. Dhurandhar’s team engineered stem cells from human fat to express a singlegene from Ad-36, called E4 ORF-1.The cells were much more likely to differentiateinto fat cells than those that did not express the gene. When they blocked expressionof E4 ORF-1 in cells infected by Ad-36, the cells failed to differentiate into fat cells-proof that this gene is both necessary and sufficient for fat cell differentiation(International Journal of Obesity , DOI: 10.1038/sj.ijo.0803748 ). Researchers maysomeday be able to block E4 ORF-1 in humans to prevent Ad-36 induced obesity109. But there’s just so much to on this before anything definitive can be said. Farmore research is needed before any practical benefits can be reaped from thisresearch. It is too early to say whether it may be possible to develop an effectivevaccine against obesity or otherwise counteract the effects of the virus.Bacteria and Obesity110, 111,112,113: While the “ diet establishment “ would like us to believe that loosing weight isas easy as exercising more and eating less, new research indicates that factors likebacteria and viruses play an important role in how our bodies metabolize and storefat. Doctors and researchers are hard at work trying to identify biological reasonswhy some people gain weight more easily than others, even when they eat similarfood. The answer may be in our gut. Our gut is full of good bacteria (microflora) aswell as bad bacteria and pathogens. Trillions of these organisms contribute to theproper functioning of our body, help us metabolize food and protect us against illness. Evaluation of Efficacy of Mushkakadi Yoga 31
    • Disease review In today’s world the bad bacteria often are out of control. Poor diet, stress,lack of sleep, or even antibiotics and other drugs can create an environment thatencourage the growth of bad bacteria, leaving us susceptible to disease, weight gainand obesity. A recent study showed that normal weight people have more Bacteroidetesbacteria in their stomach and intestines, while obese people have more Firmicutesbacteria. Researchers don’t know if Firmicutes bacteria cause obesity or if obesitycauses Fermicutes to grow, but the implications are huge: change the bacteria in yourgut to change your body. In fact, the same researchers have found that everyone’s bodies extractdifferent amount of calories from the same exact food, depending on one’s ownparticular combination of intestinal microflora Evaluation of Efficacy of Mushkakadi Yoga 32
    • Disease reviewPurvarupa of Sthoulya: Purvarupa are the symptoms that appear prior to the complete manifestation ofthe disease. (Ch.Ni.1/8) None of the Ayurvedic texts has described the purvarupas of Sthoulya.Acharya Charaka, in nidana sthana, has mentioned similar pathogenesis of Pramehaand Sthoulya114, the reason being that in both there is vitiation of kapha and meda.Therefore purvarupa of Prameha and Medovaha Strotodushti Lakshanas can beconsidered as purvarupa of Sthoulya.These are as follows: • Atinidra • Tandra • Alasya • Visra sharira gandha • Anga gaurava • Anga saithilya etc. In modern medical science there is no premonitory symptoms found in obesityor overweight. So, the mild symptoms associated with it can be considered aspremonitory symptoms. Evaluation of Efficacy of Mushkakadi Yoga 33
    • Disease reviewRupa of Sthoulya: The feature that is present after the complete manifestation of a disease isknown as Rupa of that particular disease. (Ch.Ni.1/9). Maharshi Charaka has enlistedsome cardinal features or pratyatma lakshanas of sthoulya viz: • Medomamsa ativriddhi • Chala sphika • Chala udara • Chala stana • Ayatha Upachaya • Anutsaha (Ch.Su. 21/9) Besides these cardinal symptoms, Acharya Charaka in Sutrasthana hasmentioned eight disabilities or Astha doshas of atisthoola purusha, which are asfollows115,Ayushohrasa – Due to srotorodha there is under nourishment of Dhatus other thenmeda and hence the life expectancy is decreased.Javoparodha- Saithilya, Saukumarya and Guru Properties of meda dhatu causesJavoparodha (laziness).Kricchavyavaya- Due to obstruction of genital passage by Medodhatu and lessproduction of semen, the sex act becomes difficult.Daurbalya- There is malnourishment of the Dhatus and due to this there is impairedmetabolism and hence Daurbalya.Daurgandhya- There is sweda adhikta (excessive sweating), innate quality ofMedodhatu and morbid nature of Vitiated Meda, which results in Daurgandhaya.Swedabadha- It occurs due to sang in SwedavahaSrotas by ama.Kshudhatimatra and Pipasatiyoga- Blockage of channels with MedaDhatu leads to Evaluation of Efficacy of Mushkakadi Yoga 34
    • Disease reviewincrease of kosthagata Vayu that stimulates the pachakagni leading to increase inappetite and thirst. 116 to 121Table No05: Showing Rupas of Sthoulya Describe in Ayurvedic textsNo Rupa CH SU AS AH MN BP1 Chaia Sphika + _ + + + +2 Chala Udara + _ + + + +3 Chala Stana + _ + + + +4 Ayatha Upachaya + _ + _ + +5 Udara parshva Vriddhi _ + _ + + +6 Anutsaha + _ + _ + +7 Alasya (Jadyam) _ _ + _ _ _8 Moha _ _ _ _ + +9 Javoparodha _ _ + _ _ _10 Alpa Vega _ _ + _ _ _11 Shrama _ _ + _ _ _12 Sarvakriyasu Asamrthata _ + _ _ + +13 Alpa Bala _ _ + _ _ _14 Daurbalya + _ + _ _ _15 Alpa Prana _ + + _ + +16 Ayushohrras + _ + _ _ +17 Krichh Vyavaya + _ _ _ _ _18 Alpa Vyavaya _ + _ _ + +19 Daurgandhya + + + _ + +20 Swedabadha + _ + _ _ +21 Kshudatimatra + + + _ + +22 Pipasatiyoga + + + _ + +23 Nidradhikya _ + + _ + +24 Kshudra Swasa _ + + + + +25 Krathana _ + _ _ + +26 Gadgadvani _ + + _ _ _27 Gatrasada _ + _ _ + +28 Saukumarata + + _ _ _ _ Evaluation of Efficacy of Mushkakadi Yoga 35
    • Disease reviewClinical Features of Obesity – The clinical manifestations of obesity as described in various textbooks ofModern Medicine are as under, • Obesity can be diagnosed from gain in weight. • Protuberant abdomen is a more common clinical feature of an obese person. • Development of skin fold around the axilla, breast peritoneal region is the other features present. • Dyspnoea on exertion and general lassitude. • Varicose veins and oedema of the ankles are most troublesome features of obese person. Fatty liver may be palpable in few cases. • In obese person possibility of fungal infection is greater in the skin fold areas. • In fatty women menstrual disturbance and sterility is also observed.Diagnostic methods of Sthoulya: If the disease is diagnosed in early stage we can not only stop its furtherprogress but also it is much easier to treat a disease in early stage rather than at laterstages , as has been described by Sushruta with reference to Shata KriyaKala .Diagnostic methods described in Ayurvedic texts are subjective as well as objectivetype. According to this over nutrition condition (Sthoulya) and under nutritioncondition (Karshya) both can be diagnosed by inspection only122. The measurementdescribed by Acharya Charaka and Acharya Sushruta for different Anga Pratyangasare summarized in the following table Evaluation of Efficacy of Mushkakadi Yoga 36
    • Disease reviewPramana Pariksha described in Ayurvedic texts123, 124Table No 06 Showing the Pranama ParikshaMeasurement Pramana in Angula Inch Cms Ch SuAyama (Height) 84 120 63-90 157.5- 225.00Vistar 84 __ 63 157.50Sirah Parinaha 32 _ 24 60.00(Head circumference)Sirah Ayama(Height of head) 16 _ 12 30.00Griva Parinaha 22 20 15-16.5 37.50 -(Neck circumference) 41.25Griva Ayama 04 _ 03 07.50(Height of neck)Vaksha Parinaha 48 _ 36 96.00(Vajsa24+Pitha16+kaksa8)BhujaParinaha 16 16 12 30.00Bahu Parinaha 12 - 09 22.50Udara Parinaha [abdomen 40 30 75.00circumference] [Kati-16+Udara-12+Parshva-12=[Kati=18su]SroniParinaha (Kati16+Udara- 52 _ 39 97.5012+Parshva-12+Trika-12)Uru Parinaha 30 32 22.5-24 56.3-60.00Jangha Madhya Parinaha 16 18 12-23.5 30.33 -75.00Diagnosis of Obesity125, 126: Though obesity can easily be identified at first sight butfor the purpose of precise assessment the measurements and reference standards areessential. Although there is no direct method of measuring adiposity, the most widelyused method to gauge obesity is body mass index, which is equal to weight/height2(in Kg/m2). Evaluation of Efficacy of Mushkakadi Yoga 37
    • Disease review In modern methods of diagnosis, so many parameters are described to quantify obesity. Some of them are as follows: Direct methods of measuring body fat and under water weighing (Densitometry) Estimation of fat cell mass by isotope dilution method. Estimation of total body potassium. The connective tissue (skin, bones, connective tissue) Bioelectric impedance analysis - A harmless amount of electric current is sent through the body. The body has the ability to conduct electric current, which reflects the total amount of water in the body. A higher % of body water indicates a larger amount of muscle and lean tissue. Dual energy X-ray absorptiometry - It is used to estimate bone density and provides the best assessment of the body fat. Both Computed Tomography (CT scan) and nuclear magnetic resonance to distinguish between the fat and lean tissue of the body. Most widely used criteria for diagnosis of obesity:1) Specific weight for height: Table No 07: Showing Normal Height & Weight: Height Female Male In cm Normal wt.(kg) Over Normal wt.(kg) Overwt.(+20%) wt.(+20%) (kg) (kg) 148 46.5 56.0 47.0 57.0 152 48.5 58.0 49.0 59.0 156 50.5 60.5 51.5 62.0 160 52.0 63.0 53.5 64.0 164 55.0 66.0 56.0 67.0 168 58.0 69.5 59.0 71.0 Evaluation of Efficacy of Mushkakadi Yoga 38
    • Disease review 172 60.5 72.5 62.0 74.5 176 64.0 77.0 65.5 78.5 180 67.0 80.5 68.5 82.0 184 70.5 84.5 72.0 86.5 188 74.0 89.0 75.5 90.5 * L.I.C. Standard Height/ weight index2) Body Mass Index ( BMI )/ Quetlet’s Index127 : This index is a more precise parameter to measure body fat and more accurately differentiate “Over weight “due to an increase in muscle mass from true obesity The international classification of BMI which has been widely accepted is based on the following range of BMI values:- Table No 08: Showing Grading Pattern as per BMI values Terminology BMI Underweight Below20Kg/m2 Normal 20-25 Kg/m2 Over weight 25-30 Kg/m2 Obese 30-40 Kg/m2 Very obese Above 40 Kg/m2 Table No 09: Showing Optimal BMI values: Height Body weight in kilogram (cm) 90 85 80 75 70 65 60 55 50 45 135 49.4 46.6 43.9 41.2 38.4 35.7 32.9 30.2 27.4 24.7 140 45.9 43.4 40.8 38.3 35.7 33.2 30.6 28.1 25.5 23.0 145 42.8 40.4 38.0 35.7 33.3 30.9 28.5 26.2 23.6 21.4 150 40.0 37.8 35.6 33.3 31.1 28.9 26.7 24.4 22.2 20.0 155 37.5 35.4 33.3 31.2 29.1 27.1 25.0 22.9 20.2 18.7 160 35.2 33.2 31.3 29.3 27.3 25.4 23.4 21.5 19.5 17.6 Evaluation of Efficacy of Mushkakadi Yoga 39
    • Disease review 165 33.1 31.2 29.4 27.5 25.7 23.9 22.0 20.2 18.4 16.5 170 31.1 29.4 27.7 26.0 24.2 22.5 20.8 19.0 17.3 15.6 175 29.4 27.8 26.1 24.5 22.9 21.2 19.6 18.0 16.3 14.7 180 27.8 26.2 24.7 23.1 21.6 20.1 18.5 17.0 15.4 13.9 185 26.3 24.8 23.4 21.9 20.5 19.0 17.5 16.1 14.6 13.1 ** Some therapeutic diets, national institute of nutrition, Indian Council of Medical Research, Hyderabad, IndiaSkin fold thickness128: Several varieties of calipers (e.g. Harpenden’s skin calipers) are available forthe purpose. Normally most of the adipose tissue is in subcutaneous layer, thethickness of tissue is in subcutaneous layer, the thickness of which can estimate bymeasuring a skin fold thickness at different subcutaneous sitesSites for taking measurements: • Mid triceps • Mid biceps • Sub scapular • Supra iliac regions The sum measurements should be less than 40 mm in males and 50 mm infemales. Unfortunately standards for subcutaneous fat do not exist for comparison.Further, in extreme obese people, measurement may be impossible.Relative Weight (RW) : The RW is “ actual weight” divided by “desirableweight” (derived from acceptable weight table ) • RW > 120 % Obese • RW > 200 % Morbid Obese Evaluation of Efficacy of Mushkakadi Yoga 40
    • Disease review 5) Body girth measurement: WHR129: The measurements of body circumferenceswith a measuring tape provides b the same advantages of portability andacceptability as height weight measurements. In addition circumferencemeasurement appears to be more precise and less subject to inter observer errorsthan skin fold measurement even very obese persons. Although they have foundtheir biggest use in the estimation of body fat distribution. Some studies have shown that, both men and women, who have a high ratio ofwaist to hip circumference, have increased risk of ischemic h0rt disease, stroke anddeath. Studies have shown that a greater WHR ratio is associated with higherblood pressure, glucose intolerance and higher serum lipid levels.To check the abdominal obesity one measures the waist hip ratio as given below, Waist circumference (in cm) Hip circumference (in cm) The waist circumference is measured half- way between the superior iliaccrest and the rib cage in the mid axillaries line, where as the hip circumference ismeasured one the distance between the superior iliac spine and patella.The ratio of the former to the later provides an index of the proportion of intraabdominal fat. • The average value for men is about 0.93 with range o.75 to 1.10 • The average value for women is about 0.83 and range 0.70 to 1.0 The other may be called as abdominal gluteal ratio or android gynoid ratio(AGR). Patients with an elevated AGR, i.e., greater than 0.9 for men and 0.8 forwomen are said to have android or male pattern of obesity, while patients with lowAGR are said to have gynoid or female pattern of obesity. The persons with Evaluation of Efficacy of Mushkakadi Yoga 41
    • Disease review abdominal obesity are at a greater risk of cardio vascular complications as compared to those with gluteal obesity. An easy way to determine your own desirable body weight is to use the following formula –130 • Women: 100 pounds for the first 5 feet of height plus 5 pounds for each additional inch. • Men: 106 pounds of body weight for the first 5 feet of height plus 6pounds for each additional inch. The recommended amount of body fat differs for men and women. • For women : The recommended amount of body fat is 20-21% a woman with more than 30% bodyfat is considered as obese. • For men The recommended amount of body fat is 13-17%. A man with 25% body fat or higher is considered obese. Out of the several methods described, widely and practically used methods are Weight, BMI, and Skin fold thickness measurement. In Ayurvedic classics the terms like sthula, sthoulya, medovriddi, and medoroga has been used by the Acharyas in different contexts, some times often taken as relative terms, but by observing the references and signs and symptoms sight changes can be observed in the pattern of medovriddi, medodosha, sthoulya etc. Unlike this in modern medicine the international classification like BMI has been widely accepted as the basis for defining the terminologies like under weight, normal weight, over weight, obese and morbid obese. The most probable reason for this may be that BMI is same for both sexes and for all ages of adults and it takes into Evaluation of Efficacy of Mushkakadi Yoga 42
    • Disease reviewconsideration weight as well as height. Further more it helps to determine risk ofcertain diseases, including diabetes and hypertension Evaluation of Efficacy of Mushkakadi Yoga 43
    • Disease reviewSamprapti of Sthoulya: - Samprapti refers to the manner in which a disease manifests starting fromdosha dushti to the appearance of clinical features. The knowledge of Samprapti isessential for the comprehension of specific features or vyadhi ghatakas of a diseaselike Dosha, Dushya, Srotodushti, Ama, Agni. Its knowledge is also essential for thepurpose of chikitsa of a disease as the basis of chikitsa according to Ayurvea isdosha- dushya samurchana vighatana or samprapti nasha. Basically sthoulya has beenconsidered as a dushya dominant disorder i.e. Medoja vyadhi131. In some other placesit has been described as meda doshaja disorder132.Samanya samprapti : According to Charaka, due to avarana (obstruction) of all the srotas (channels)by the meda, there is vriddhi of kosthagata vata (samana vayu) which in turn causesati sandhukshana of jathragni. The increase in jathragni leads to rapid digestion ofconsumed food and leaves the person craving for more food. If at all due to somereason the person does not receive more food the increased agni causes dhatu pachanawhich may lead to various complications. But consuming the food more frequentlyresults in meda vriddhi which ultimately leads to Sthoulya133. According to Sushruta, Kaphavardhakahara, Adhyasana, Avyayama,Divaswapna etc. leads to formation of Ama Rasa (Apachita Adhya Rasa Dhatu ) . The Madhura Bhava Ama Rasa moves within the body, the Snigdhansha of thisAma Rasa causes srotosanga and excessive stoutness which leads to Sthoulya134. Evaluation of Efficacy of Mushkakadi Yoga 44
    • Disease reviewFlows chart No 01: Schematic representation of samprapti of sthoulya. Nidana sevana Beeja swabhava Koshtagi dushti Madhurtara annarasa utpatti Ama Medodhatwagni Mandhyata Atisneha utpatti Medo Dhatu Atiupachaya Ati meda avarana Vatavriddhi in kostha Ati vridda Meda Dhatu causes Anya Dhatu Margavarodha Jathragni atisandukshana Ati ahara sevana Anya Dhatu Asamyak Upachaya STHOULYA Evaluation of Efficacy of Mushkakadi Yoga 45
    • Disease reviewVishesha samprapti: Samprapti of all the diseases are explained under someimportant components (vyadhi ghataks) as below,Dosha: In the samprapti of Sthoulya all the three doshas are involved. AcharyaCharaka135 has considered Sthoulya as one among the Kaphajananatmaja vyadhi.Considering the nidanas of Sthoulya, which are same as kaphakaraka nidanas such asguru, snigdha, sheeta, and madhura ahara sevana, diwaswapna etc, can easily proveths fact. Basically in tha samprapti of Sthoulya involvement of Pachaka and Brajakapitta can be observed by seeing the lakshanas like atikshuda, atipipasa, atisweda etc. Due to the avarana of the srotases by meda the kosthagata vata (samanavayu) gets aggravated which in turn leads to atisandukshan of agni resulting in rapiddigestion of the consumed foodand the person keeps craving for more food and hencethe food intake increases and because of vitiation of vyana vayu there is impairedcirculation and distribution of meda.Dushya: While Acharya Charaka has considered Sthoulya as a dosha pradhan vyadhi,Acharya Sushruta has laid more emphasis on dushya and has mentioned Sthoulya as aDushya dominant disorder136. Here, Rasa, Mamsa, Meda, Majja and Shukra dhatusare the Dushyas as Kapha is seated in all these Dhatus on the basis ofAshrayashrayeebhava. So, vitiation of Kapha also leads to vitiation of aboveDushyas137.Srotas: In Sthouya, the theinvolvement of Medovaha srotas is the main factor alongwith the involvement of other srotases like, Rasavaha srotas and Mamsavaha srotas.Charaka considered avyayam, divaswapna, excessive intake of medura dravyas and Evaluation of Efficacy of Mushkakadi Yoga 46
    • Disease reviewvaruni or madya as causes of meda vaha srotas dushti138. And as the deposition ofmeda is seen inside the vasa (muscle) the involvement of Mamsavaha srotas is alsopresent.Agni: “Rogo sarveapi mandagnou “, Acharya Charaka has high lightened the roleof Agni in the manifestation of each and every disease including Sthoulya , in UdaraChikitsasthana. In Sthoulya due to srotorodha by Meda there is aggravation ofkosthagata vata (samana vata ) which causes jathragni atisandukshan and because atthis stage the person is in urgent need of food ,he consumes whatever is available,irrespective of time, he goes for kalavyatheeta and adhyasana type of ahara sevana,which further leads to formation of amaAccording to Vagbhata, the Agni present atthe dhatu level is dhatwagni and it’s a part and parcel of jathragni as both performsthe identical function though at different levels. The increase or decrease of particulardhatwagni leads leads to vriddi or kshaya of that particular dhatu. In the state ofDhatavagnimandya, kshaya of utterouttter dhatu takes place139. In sthoulya, there is vitiation of medadhatwagni poshakamsha due to whichthe meda dhatwagni is unable to perform its function properly. This causes formationof more meda dhatu poshaka rasa and hence accumulation of more meda dhatu. Atthe same time there is kshaya of utter dhatus viz, Asthi, Majja and Shukra.Ama: Ama is one of the most important factors in the samprapti of Sthoulya. It’s awell-known fact Ama results from agnimandya and hence in this case also there mustbe agnimandya either at jathrgni level or dhatwagni level or at both levels. Excessiveintake of sheeta, snigdha, & madhura ahara leads to jathragnimandya as these gunasare opposite to that of Pitta. This leads to formation of jathragnijanitaama and there is Evaluation of Efficacy of Mushkakadi Yoga 47
    • Disease reviewfurther accumulation of Ama in Medovaha srotas. Ama formation also takes place asaresult of Medodhatwagni mandya140. Samprapti Ghatakas: -Dosha : Kapha : Kledaka Pitta : Pachaka Vata : Samana , VyanaDushya : Rasa, Mamsa & Meda dhatuAgni : Jathragni Rasa and Meda Dhatvagn Srotas : Meda vaha srotas Rasa vaha srotas Sweda vaha srotas Udaka vaha srotasSroto Dusht : Sanga Margavoroddha (Ch. Su.- 21/3-4 ) Amatah (Su.Su.- 15/37)Adhisthan: Particularly Vapavahana & Meda dhatu kalaUdhbhava sthana : AmashyaSanchara sthana: RasayaniRoga marga : BahyaVyaktsthana : Sarvanga , Specifically Sphika Udara , Stana &Gala.PATHOGENESIS OF OBESITY141: An obese person has one or both of the following conditions,• An increase in number of adipose cells, i.e. hypertrophy And / or Evaluation of Efficacy of Mushkakadi Yoga 48
    • Disease review• An increase in size of adipose cells, i.e., hyperplasia These conditions may arise either due to functional demand in particular ageor sex or due to genetic, endocrine, behavioral, psychological or iatrogenic factors.The characteristic feature of adult onset of obesityis that in this type of obesity predominantly adipose cell hypertrophy is present withminimum hyperplasia. The three main factors in the pathogenesis of obesity are:Excessive lipid deposition: Excessive lipid deposition may take place due to following factors,• Increased food in take - Increased food intake in the form of carbohydrates, proteins, and fats, by metabolic processes, lastly converts into fat and gets stored at fat depots.• Hypothalamic lesions: Hypothalamus is the centre of hunger and hence physiology of hunger as well as satiety is dependent upon hypothalamus. Lesions may damage these centers and lead to voracious appetite (Ventro medial and lateral nuclear area of hypothalamus) which ultimately leads to obesity.• Adipose cell hyperplasia or hyperlipogenesis: Genetic or endocrine pathology may lead to adipose cell hyperplasia which results in obesity.Diminished lipid mobilization: Mobilization of unsaturated fatty acids is s under the control of thyroxin,adrenaline and glucocorticoids. Hypo secretion of thyroxin and hyper secretion ofglucocorticoids causes diminished mobilization of lipid and thus there is excessivelipid deposition in certain areas such as abdomen, chest, face and buttocks, ultimatelyleading to obesity. Apart from this thyroxin also increases the appetite and foodintake. Evaluation of Efficacy of Mushkakadi Yoga 49
    • Disease reviewDiminished lipid utilization: It is due to ageing, defective lipid oxidation, defective thermo genesis orinactivity. The BMR increases to 60-100% above normal level, when large quantityof thyroxin is secreted. It falls to 20-40% below the normal level when less quantityof thyroxin is secreted. This is the main pathology of middle aged obesity.Pathology of Viral obesity142: Last year researchers AT Louisiana University at Baton Rouge showed thatAd-36 virus causes precursor cells to differentiate into fat cells, and could promoteobesity in humans and animals. Later on it was proved that a single viral gene isresponsible for triggering this process. Though the researchers do not know exactlyhow this adenovirus causes obesity but it was observed that infected animals do noteat more than the uninfected ones, suggesting that the virus decreases energyexpenditure rather than increasing appetite. Evaluation of Efficacy of Mushkakadi Yoga 50
    • Disease review Figure No.02: Showing the etiology of Obesity ETIOLOGY• Increased food intake • Decreased Lipolytic • Ageing• Hypothalamic Hormones. • Defective lipid Lesions • Defective Adipose Cells Oxidation• Adipose cell • Abnormality in • Defective thermo hyperplasia autonomous Innervations. genesis.• HyperlipogenesisIncreased lipid deposition Diminished lipid Diminished Utilization mobilization OBESITY Metabolic changes related to obesity143: Hyperinsulinaemia: Increased insulin secretion is a feature of obesity. Many obese people exhibit hyperglycemia or frank diabetes despite hyper insulineamia. This is due to a state of insulin – resistance consequent to tissue insensitivity. NIDDM: There is strong association of NIDDM with diabetes. Obesity often exacerbates the diabetic state and in many cases weight reduction often leads to amelioration of diabetes. Evaluation of Efficacy of Mushkakadi Yoga 51
    • Disease reviewHypertension: Association of this with obesity is because of increased blood volume.Weight reduction leads to significant reduction in systolic blood pressure.Hyper lipoproteinaemia: The plasma cholesterol circulates in the blood as lowdensity lipoprotein (LDL) containing most of the circulating triglycerides. Obesity isstrongly associated with VLDL and mildly with LDL. The blood cholesterol levelsare elevated in obesity.Atherosclerosis: In hypo secretion of thyroxin, the cholesterol level in plasmaincreases leading to arthrosclerosis. Obesity predisposes to development ofatherosclerosis.Coronary artery disease and stroke: In obese people there is increased risk ofmyocardial infarction and stoke due to atherosclerosis and hypertension.Cholelithiasis: There is six times higher incidence of gallstones in obese persons,may be due to increased body cholesterol.Hypoventilation syndrome (Pickwickian syndrome): This is characterized byhyper-somnolence, both at night and during day in obese individuals along withcarbon dioxide retention, hypoxia, polycythaemia and eventually right-sided heartfailure.Osteoarthritis: These individuals are more prone to develop degenerative jointdisease due to wear and tear following trauma to joints as a result of large bodyweight.Cancer: Certain cancer such as endometrial and breast seems to be related toobesity. In case of colon cancer, the main cause is excessive intake of diets derivedfrom animal fats and meats. High fat intake increases the level of bile acids in thegut, which in turn modifies intestinal flora, favoring the growth of micro aerophilicbacteria. Evaluation of Efficacy of Mushkakadi Yoga 52
    • Disease reviewUpadrava of Sthoulya144: The aliment, which is associated with a disease, and is manifested after themanifestation of the main disease, is called Upadrava.Describing the severity of Sthoulya, Charaka has compared the aggravated vata andpitta with davanala, which destroys the whole forest.Table No 10: Showing upadrava of Sthoulya145, 146,147,148,149,150:Sl No Upadrava SU AS AH MN BP YR1 Ama Roga _ _ + _ _ _2 Apachi _ _ + _ + +3 Arsa _ + + _ + +4 Atisara _ _ _ _ + +5 Bhagandara + + + + + +6 Jwara + + + + + +7 Jantavaha _ _ _ _ + +8 Kaamala _ _ _ _ + +9 Kasa _ _ + _ _ _10 Kustha _ _ + _ + _11 Mutra Kriccra _ _ + _ _ _12 Prameha _ + + _ + +13 Pramehapidika + + _ + _ _14 Shleepada _ _ _ _ + +15 Sanyasa _ _ + _ _ _16 Udararoga _ + + _ _ _17 Urusthambha _ + _ _ _ _18 Vatavikara + _ _ + _ _19 Visarpa _ _ _ _ + +20 Vruddhi + + _ + _ _ Evaluation of Efficacy of Mushkakadi Yoga 53
    • Disease review Upadrava of Sthoulya Due to agnivikriti Medamamsavikriti Avaranam Swedabaha Ojadushti Prameha, Urustambha Kustha,Atisara, Pidaka , Vatarakta, Jantvaha. Swasa,Ajirna, Apachi, Sandhivata, Etc Kasa,Udararoga, Slipada, Gridrasi, Sanyasa Granthi, Damaniprath Vidrahi, - ichaya etc Flow Chart No02: Schematic representation of Upadrava Sthoulya Complications of obesity151, 152,153: Obesity leads to serious health consequences. Risk increases progressively as BMI increases. Raised body mass index is a major risk factor for chronic diseases. Obesity is termed as the storehouse of diseases as well as a leading cause of morbidity and mortality due to its manifold complications. Statistics on health shows that a middle aged person who is 10 kg overweight can expect to die roughly 4 years earlier then one with normal weight. Obese women are more likely than non-obese women to die from cancer of the gall bladder, breast, uterus, cervix or ovaries. The complications related with obesity can be classified according to various systems as follows: Cardio Vascular System: Cardio-vascular diseases (mainly cardiac arrest & stroke) are already world’s number one cause of death (according to WHO), leading to death of nearly 17 million Evaluation of Efficacy of Mushkakadi Yoga 54
    • Disease reviewpeople per year. Obesity is mainly associated with cardiomyopathy, pulmonaryhypertension of obesity, cardiac arrhythmias, left ventricular hypertrophy andatherosclerosis.Respiratory systems: The main complications associated with obesity are chronic bronchitis,hypoxemia, alveolar hypoventilation, hypoventilation syndrome (Pickwickiansyndrome), pulmonary hypertension, pulmonary embolism, and obstructive sleepapnoea.Gastro intestinal system: Gall Stone, Hiatus Hernia, Cholecystitis, Pancreatitis, Hepatic Stenosis,Diverticulitis of colon, Reflux Oesophagitis, Dyspepsia are the main G.I.T. diseasesassociated with obesity.Central nervous system: The main symptoms associated with obesity are stroke, idiopathic intracranialhypertension, and neuralgia paresthetica.Malignancies: The main carcinomas associated with obesity are endometrial, prostate, gallbladder, breast, colon, and possibly lung cancer.Musculo skeletal: Mainly osteoarthritis and backache are associated with obesity.Endocrine and metabolic: The main complication associated with obesity is Diabetes Mellitus, whichhas already become a global epidemic. WHO projects that the death toll due todiabetes will increase by 50% in next 10 years. Other complications associated with Evaluation of Efficacy of Mushkakadi Yoga 55
    • Disease reviewobesity are hyperlipideamia, hypo metabolic state, hyper cholestraemia, fatty liver,gout and polycystic ovarian syndrome.Miscellaneous: Other complications associated with obesity are reduced mobility,difficulty in maintaining personal hygiene.Sadhyasadhyatva of Sthoulya: Charaka, in Chikitsa sthana while describing Prameha chikitsa, has clearlymentioned that any disease that kulaja (hereditary) or beejaswabhavaja is asadhya.Thus, Sahaja Sthoulya can be considered as Asadhya154.Therefore Sadhyasadhyata ofSthoulya can be decided on the basis of general principles depicted in Ayurvedic texts(Ch.Ni. 8 / 33-35), which are as below, Table No.11: Showing the Sadhyaasadhyatva of Sthoulya SthoulyaSukhasadhya Krichhasadhya AsadhyaJatotara Hina Sthoulya Jatotara Madhyama Sahaja Sthoulya,JatotaraHaving duration of 1-5 Sthoulya Adhika Sthoulyayears. Having duration of 5-10 Having more than 10Without having any years. years of durationcomplications or With least complications Associated with secondarysecondary disease. but no secondary disease. complications.Prognosis of Obesity155: Obesity leads to serious health consequences. Risk increases progressively asBMI increases. Raised body mass index is a major risk factor for many chronicdiseases. There is evidence that risk of chronic disease in population increasesprogressively from a BMI of 21. The morbidity-associated obesity is not unknown. The relative risk ofcoronary heart disease is more in a person with BMI 25-28 Kg/m2. The risk Evaluation of Efficacy of Mushkakadi Yoga 56
    • Disease reviewprogressively increases with an increasing BMI. Therefore, person with BMI greaterthan 33 Kg/m2 has relatively high risk of coronary heart disease. Similar trends havebeen observed in the relationship between obesity and stroke or congestive heartfailure. Overall obesity is estimated to be associated with a 4-fold increase in cardiovascular mortality rate and a2-fold increase in cancer related mortality rate. In sort,people who are severely obese have a 6-12 fold increased mortality rate due one orthe other factor Evaluation of Efficacy of Mushkakadi Yoga 57
    • Disease reviewChikitsa of Sthoulya: According to Acharya Charaka, all the actions that leads to the restoration of theequilibrium of Doshas (vitiated doshas), constitute the Chikitsa of a disease. The mainobjective of Chikitsa is to ensure that the doshas do not get vitiated and also tomaintain the equilibrium of doshas in the body. Thus Chikitsa aims not only at theradical removal of the causative factor of the disease, but also at the restoration of theDoshika equilibrium.In Ayurveda, there are various classifications of Chikitsa, such as – • Dev vyapashrya, Yukti vyapashrya & Satvajya Chikitsa • Swasthaurrjasyakarma & Aturasya rogaharam • Anta parimarjana, Bahira parimarjana & Shastra praridhana • Santarpana & Apatarpana chikitsa Many more classifications are available in different Ayurvedic texts but thegeneral principle adopted in the management of any disorder is the SamsodhanadiTrividha Chikitsa mentioned by Charaka in Vimanasthana (Ch.Vi. -7/28) CHIKITSASamsodhana Therapy Samshamana Therapy NidanaParrivarjanSamsodhana Therapy:Table No.12: Showing methods of samsodhana therapy in SthoulyaBahir Parimarjana Chikitsa Abhyantara SamsodhanaUdvartana VamanaAvagaha VirechanaParisheka NasyaLepa Niruha vasti Evaluation of Efficacy of Mushkakadi Yoga 58
    • Disease reviewBahir parimarjana chikitsa: There is description of external purification therapy in the management ofSthoulya. Acharya Charaka has mentioned Rooksha Udavartana for Sthoulya156.Vaghbhatt has mentioned the benefits of Rooksha Udavartana like Kaphahara,Medasa Parivilayana, Sthirikarnam Angam etc. (A.H.Su.2/15).Abhyantar Samsodhana: Vagbhata has advocated the use of Samshodhan therapy including Vamana,Virechana, Rooksha Niruha, and Raktamokshana etc. in Atisthoola persons withBahudosha and Adhika Bala157. Charaka has considered Sthoulya as a Santarparnajanya vyadhi and hasrecommended the use of Vamana, Virechana, and Raktamokshana in allSantarparnajanya vyadhis including Sthoulya158. Besides this he has also mentionedRooksha, Teekshna, Ushna vasti for the management of Sthoulya. Charaka has contraindcated Snehapana in Sthoola purusha but at the sametime he has mentioned that if vamana, virechana etc samsodhana therapy is needed tobe given to such a patient than he shold be given Katu, Tikta, Kashaya rasa pradhanadravyas and then snehpana can be done followed by samsodhana therapy.Similarview has been given by Vagbhatta.Besides this Vagbhatta has also advocated the useof Taila in Sthoulya due to its Sookshmagamitava property because of which itreduces margavarodha.( A. H. Su.5/55-56) .Sushruta and Vagbhatta , both, havementioned Lekhaniya, Medohara &Stoolahara properties of Taila(Su Su 45, Su.Chi.31/16, A.S. Su.6/100). Similarly, Niragni Sweda in the form of Vyayama, Atapasevana,and Upanaha can be recommended in the patient of Sthoulya159. Evaluation of Efficacy of Mushkakadi Yoga 59
    • Disease review Vamana and Virechana have also been mentioned by various Acharyas in themanagement of Sthoulya on the principle that they cause laghuta in the body andirradicates the meda dourgandhya.160, 161,162 A number of Vasti kalpas are also mentioned in Ayurvedic texts but Lekhanavasti is considered as the best therapy for Sthoulya/ Medovriddi163. Sharangdhara hasgiven a clear description regarding the properties of lekhana dravyas andcharacteristics of lekhana vasti164. Maharshi Kashyapa and Bhavamishra have recommended Rakta mokshanafor the treatment of Sthoulya165. Kashyapa has mentioned Karshana nasya as atreatment for all kaphaja disorders including Sthoulya166. Sushruta has recommendedthe use of Triphaladi taila nasya in the patients of Medovriddhi167.Samshamana Therapy: Charaka has mentioned the treatment for Sthoulya in following words: GuruCha aptarpana, i.e. administration of Guru and apatarpaka dravyas, which possess theadditional properties of Vataghna, Kaphahara and Medonashaka, are considered as anideal for Samshamana therapy. Similar views have been expressed by Chakrapani,according to whom, Guru guna has the property of alleviating the vitiated agni andAptarpana provides less nourishment and hence reduces meda. The best example ofsuch a dravya is madhu (honey). It has the properties of gurutva and rookshatva andhence is ideal for the management of Sthoulya. Gangadhara has interpreted that Guruproperty is suitable to alleviate Tikshnagni and vitiated vata especially KosthagataVata, which ultimately reduces Atikshuda and Apatarpana property, causes reductionof Meda168. But while following the principle of Guru Cha Apatarpanam, one shouldalways remember that both guru and apatarpaka properties must be present Evaluation of Efficacy of Mushkakadi Yoga 60
    • Disease reviewsimultaneously as the consumption of only guru dravyas like Ghrita, Taila, Vasa etc.by Stoola purusha will further increase the meda and thus detiorating the condition.Similarly if only Apatarpana therapy (Upavasa, langhana etc.) is used then it willincrease the already increased kosthagata agni and vayu which may have seriousconsequences and may even cause death. While describing the chikitsa of Sthoulya, Charaka has also narrated thatSthoolamevatipidyeta meaning thatit is very difficult to treat Atisthoola people as ifKarshana therapy is applied then it leads to further aggravation of alreadyaggravated jathragni and vayu and if Brimhana therapy isapplied it further increasethe Meda169. Charaka has mentioned many dravyas for the management of Sthoulya suchas170: Guduchi Nagaramotha Triphala Takra arishta Vayavidanga Sunthi Various Kshars Bilvadi panchamoola Agnimantha rasa with Shilajeet etc A number of yogas have been described in various Ayurvedic texts for themanagement of Sthoulya. Evaluation of Efficacy of Mushkakadi Yoga 61
    • Disease reviewNidana Parivarjana: Both Charaka and Sushruta have laid great emphasis on the principle ofNidana Parivarjana. Sushruta in particular has recommended nidana parivarjana as anessential component in the management of any disorder, as can well is interpreted bythe following sutra of Sushruta, Sankshepa Kriyayoga Nidana Parivarjanam. Nidana Parivarjana chikitsa means avoiding all the aharatmaka, viharatmakamanasika and anya nidana responsible for the manifestation of a disease. Such as atimadhura,guru snigdha ahara sevana divaswapna, ati harsha etc. should be avoided incase of Sthoulya.Treatment of Obesity:Prevention: Prevention should begin in early childhood. Obesity is harder to treat in adultsthan it is in children. Obesity as well as its related chronic diseases is largelypreventable.At the individual level, people can: Achieve energy balance and a healthy weight; Limit energy intake from total fats an shift fat consumption away from saturated fats to unsaturated fats; Increased consumption of fruit and vegetables, as well as legumes, whole grams and nuts; Limit the intake of sugars; and Increase physical activity – at least 30 minutes of regular moderate-intensity activity on most days.The treatment of Obesity can be narrated under following headings, Counseling of the patient Evaluation of Efficacy of Mushkakadi Yoga 62
    • Disease review Diet therapy Behavioral modification Exercise therapy Drug therapy SurgicalCounseling of patient: Counseling of the patient is very essential for the management of any disease.Patient must be given proper knowledge about the nature of the disease its etiologicalfactors as well as treatment and complications. Emphasis should be laid on fatreduction rather than weight loss. Patients must be made aware of the role of diet inthe manifestation as well as management of Sthoulya. At the same time, must be disposed with confident opinion concerning thesuccessful outcome of the prescribed programs as well as importance of gradualweight loss instead of drastic. The weight will be very rapid in early period of dietingand then gradual. This should be explained to the patients before hand to avoiddisappointment.Diet Therapy171: Diet therapy mainly focuses on the weight management, which depends on theintake as well as expenditure of calories. For any obese person, the quantity of foodintake and the avoidance of settings in which excess quantities of high fat food areeaten are equally important. Dieticians suggest ingestion of frequent small meals withhigh carbohydrate and high fiber content, as it is an effective way of decreasing fatintake.Calories for Weight Maintenance172: To maintain the weight, WHO hasrecommended the following formula Evaluation of Efficacy of Mushkakadi Yoga 63
    • Disease review • 10 calories per pound of desirable body weight if you are sedentary or very obese • 13 calories per pound of desirable body weight if your activity level is low, or if you are over age 55 • 15 calories of desirable weight if you regularly do moderate activity • 18 calories per pound of desirable body weight if you regularly do strenuous activityActivity levels: 1. Low activity: No planned, regular physical activity; occasional weekend or weekly activity (such as golf or recreational tennis) is the only type of physical activity 2. Moderate activity: Participating in physical activities such as swimming, jogging, or fast walking for 30-60 minutes at a time 3. Strenuous activity: Participating in vigorous physical activity for 60 minutes or more at least 4-5 days per week While planning diet schedule for an obese patient caloric intake should be reducedby 500-1500 calories per day from the current level and perfect aim should be fixed.Middle aged obese house wife need 800-1000 kcal per day where as an obese manengaged in active physical activity, need 1500-2000 kcal per day. Rigid dieting is besttreatment. Low Calorie Diet (LCD), i.e, 800-900 calories per day is best to reduceweight. But it must contain all the essential foodstuffs. Diet lower than 800 kcal perday (VLCD) is found to be no more effective than LCD in producing weight loss ona long-term basis173.A Balanced diet174 • Do not eat meat more than once a day Evaluation of Efficacy of Mushkakadi Yoga 64
    • Disease review • Eat fish and poultry more often than red or processed meats because they are less fattening • Avoid frying food. Fried food absorbs the fats from the cooking oils, increasing your dietary fat intake. Instead bake or boil food. If you do fry, use polyunsaturated oils, such as corn oil. • Cut down your salt intake. Limit table salt, or flavors intensifiers that contain salt, such as monosodium glutamate (MSG). • Include adequate fiber in your deiet. Fiber is fiund in green leafy vegetables, fruit, beans, bran flakes, nuts, root vegetables, and wholegrain foods. • Do not eat more than 4 eggs per week. Although they are a good source of proteins and they are low in saturated fat, eggs are very high in cholesterol. • Choose fresh fruit for dessert, rather than cookies, cake, or pudding.Contraindications: In spite of its critical role in the management of obesity, VLCDs and LCDsare contraindicated, absolutely or relatively, in some conditions. These includeconditions like pregnancy, adolescents, growing children and patients with significantliver, kidney and cardiac disorders. In addition there are some other conditions whereLCDs and VLCDs are advisable only under medical supervision. These includecoditions like gout, diabetic patients taking insulin or hypoglycemic agents, pre-existing gall bladder disease and hypertensive patients on anti hypertensive drugs.Starvation175: Fasting as a method of management of obesity is of great advantage as itcauses dramatic drop in weight within one week of treatment, which may ofpsychological benefit for the patient. Total starvation for about 5-10 days prior tomore conventional dietary therapy may be justified only when conditions like, gout, Evaluation of Efficacy of Mushkakadi Yoga 65
    • Disease reviewrenal insufficiency and ketosis prone diabetes are completely ruled out. Probably themotive of total fasting is that it acts as a motivational aid at the beginning of dietaryprogrammed or when weight loss has stopped. The major problem in the treatment ofobesity is not weight reduction but maintenance of reduced weight.Behavioral modification176: The principles of behavioral modification provide the underpinnings for manycurrent programs of weight reduction. The basic principles are those of operantconditioning and cognitive restructuring. Eating behavior is analyzed into itsantecedents, the act of eating, and the consequences of eating by asking the patient tomonitor and record these activities. The setting in which eating occurs, the eating event itself and the use of rewardsdesigned to change maladaptive behaviors are all monitored. Attempts are made tochange the thinking patterns of the patients and to motivate them for taking upphysical exercises. Features of behavior modification of proven value in people whoare successful in maintaining the weight loss over an extended period of time include • Continued monitoring of food related behaviors, • Adoption of a low-fat diet, and • Increased levels of physical activity.Exercise therapy177: The root cause of obesity is the imbalance between the energy gained andenergy expenditure. Regular physical exercise, which can be maintained in the longterm, proves beneficial in the management of obesity. Such exercises need not beover strenuous because health gain is achieved at modest levels of exercise, as long asthese are maintained. Walking briskly for 30mins each day can result in an additionalweight loss of 1kg per month. Aerobic exercises in particular helps in increasing Evaluation of Efficacy of Mushkakadi Yoga 66
    • Disease reviewmuscle tissue and burning calories. Hence balanced physical activity with diet hasbeen recommended for maintaining desired weight.Towards a possible vaccine against obesity178: In what could prove to be a blessing in disguise for the obese people,scientists have had an initial success with an experimental vaccine for obesity. Afteradministration of a vaccine against a hunger hormone called ghrelin, the animals wereable to live the dream of eating what they wanted without packing on body fat.Ghrelin is a hormone primarily secreted by the stomach and helps in regulatingappetite, metabolism and weight-Reuters. According to Dr.Kim Janda of the Scrippsresearch institute in Iajolla, California, it is still a long way before similar results inpeople can be achieved and more research in animals and more data on safety will beneeded before an obesity vaccine is widely tested in humans. Now further researchneeds to be done to see if the ghrelin vaccination gives similar results in alreadyobese rodents as it produced in non-obese rats. And if this vaccine becomes a realityfor humans then it would be targeted at those obese individuals who continually “YO-YO” in spite of undergoing diet and exercise therapy. This finding, published onlineby the proceedings of national academy of sciences, suggests a whole new approachto weight loss.Drug therapy179: Obesity is the result of the imbalance between energy gained and energy spentor in other words a positive state of energy balance results in obesity. Hence,antiobesity drugs must be aimed at maintaining the state of negative energy balancein the body, until the desired weight loss is achieved. Appetite suppressant drugs areuseful in this condition. Evaluation of Efficacy of Mushkakadi Yoga 67
    • Disease review There are two groups of drugs which acts as appetite suppressants, viz. – thoseaffecting hypothalamic catecholaminergic pathway (e.g. amphetamine,diethylepropione, phentermine and mazindol ) and those affecting the hypothalamicserotinergic system (e.g. fenfluramine, dexfenfluramine). Amphetamines are synthetic compounds, which stimulates respiratory centreand suppresses hunger. Hunger is suppressed as a result of inhibition of hypothalamicfeeding centre. But because of adverse central effects; the use of amphetamines tosuppress appetite cannot be justified. A number of related drugs have been developedwhich inhibit feeding centre but have little or no CNS stimulant action or abuseliability. All of them act by inhibiting the reuptake of Noradrenergic/Dopaminergic or5-HT, enhancing monoaminergic transmission in the brain. The noradrenergic agentssuch as phentermine, diethlepropionand mazindol, primarily affect the appetite centrewhile the serotonergic agents such as fenfluramine, affect the satiety centre anddecreases food intake by enhancing serotonergic transmission in the hypothalamus. Itreduces food seeking behavior as well as decreases quantity of food consumed at anymeal. A minor effect to increase basal metabolic rate is also reported180. Two new drugs are also available, namely, Sibutramine and Orlistat.Sibutramine is an orally administered centrally acting weight management agentapparently devoid of amphetamine-like abuse potential. Its primary and secondaryamine metabolites are pharmacologically active and are thought to induce the naturalprocesses leading to enhancement of satiety and thermo genesis by inhibitingserotonin (5-HT) and noradrenaline reuptake. Metabolic rate may also be enhancedby stimulation of peripheral beta -3 adreno receptors. Weight loss achieved with thisagent is 3-5kg better than placebo with 6 months therapy and is associated with animprovement in lipid profile Evaluation of Efficacy of Mushkakadi Yoga 68
    • Disease review The other drug, Orlistat, is a reversible inhibitor of lipases. It exerts itstherapeutic activity in the lumen of the stomach and small intestine by forming acovalent bond with the active serine residue site of gastric and pancreatic lipases. Theinactivated enzymes are thus unavailable to hydrolyze dietary fat in the form oftriglycerides into absorbable free fatty acids and monoglycerides. As undigestedtriglycerides are not absorbed, the resulting caloric deficit may have a positive effecton weight control.Surgical management181: Surgical treatment is advised for morbidly obese persons with 100% weight abovethe weight for height standards and who have failed to loose weight by all othermeans. This treatment can be categorized as follows: • Excision effect: This form of surgery is not very popular and is hardly done now days as in this, the obese patient is exposed to the risk of anesthesia, surgery and poor wound healing. • Surgery to cause malabsorption: It refers to the jejuno-ileal by pass surgery, where the upper jejunum is divided. The distal end is closed and the proximal end is anastomised either ends to side or end to end to the distal ileum. But the main drawback of this procedure is that decreased absorption of nutrients results in diarrhea and long-term metabolic complications may also arise. • Operation to restrict the food intake: It includes procedures such as gastric by pass and gastroplasty (or gastric reduction operations). A new stomach is surgically constructed from the upper part of the normal stomach. This causes a sense of fullness and hence limits the intake of food.Baratric surgery182: These include 5 surgical methods performed for themanagement of obesity – Evaluation of Efficacy of Mushkakadi Yoga 69
    • Disease review• An adjustable gastric band• Vertical banded gastroplasty• A biliopancreatic bypass• A Rouse-en-y gastric bypass• A sleeve gastroctomy with duodenal swith. Evaluation of Efficacy of Mushkakadi Yoga 70
    • Disease reviewPathya – apathya of Sthoulya: Ancient Ayurvedic classics have laid much more importance upon withPathyapathya in the treatment of a disease. Without obeying the rules ofPathyapathya, a patient will never get satisfactory result; rather a disease mayaggravate apathya sevana. All those dietary items and physical activities that are best for srotases andare of Mana’ s likening or in other words are beneficial (hitakaraka) for both shareera(body) and mana (mind) are called Pathya and those with opposite qualities are calledApathya. Table No 13 Showing Pathya for Sthoulya183, 184,185,186,187.Sl No Pathya CH SU AH AS YR BP1 Puran Shali - - - + + +2 Prashatika + - - - - -3 Priyangu + - - - - +4 Shyamaka + + + + - +5 Yava + + + + + +6 Yavaka + - + - - -7 Jurna + - - - - -8 Kodrava + + - + + +9 Udalaka - + - + - -10 Nivara - - - - - +11 Laja - - + + + +12 Mudga + + + + + +13 Kulattha + - + + + +14 Chakra Mudga + - - - - -15 Makusthaka + - - - - -16 Adhaki + - - - - -17 Chanaka - - - - - +18 Masura - - - - - + Evaluation of Efficacy of Mushkakadi Yoga 71
    • Disease review19 Patola + - - - - -20 Vartaka - - - - - +21 Vruntaka - - - + + -22 Patrasaka - - - - - +23 Adraka - - - - + -24 Bimbi - - - + + -25 Amalaki + - - - - -26 Tambula - - - - + -27 Madhu - + - + - +28 Madhudoka + - + - - -29 Arishta + + - - - -30 Takra - - - - - +31 Mastu - - + - - -32 Sura - - - - - +33 Sarshap Tail - - - - - +34 Tila Tail - - - - - +35 Ushnodaka - - - - - +36 Kanji - - - + - -37 Rohit Matsya + - - - - -38 Chingat Matsya - - - - - +39 Jangal Mamsa + + + + + -40 Vyayama - + - - - -41 Shrama - - - + - +42 Jagarana - - + + - +43 Vyavaya - - - + - +44 Yana Bhramana - - - + - +45 Chinta - - - + - +46 Aguru Lepa - - - - - +47 Udvartana - - - - - +48 Atapa - - - - - +49 Apatarpana - - - + - +50 Vamana - - - - - + Evaluation of Efficacy of Mushkakadi Yoga 72
    • Disease review51 Virechana - - - - - +52 Lekhan Vasti - + - - + -53 Shodhana - - + - - -54 Langhana - - - - - +55 Prag Bhojane Varipana - - - - - +56 Nishkale Ushnodakapana - - - + + -57 Katu Tikta Kashyaya Rasa - - - - - +58 Ruksh anna - + - - - -59 Saktu - - - + + -60 Guggulu - - - - - +61 Kshara + - - - - -62 Ayash - - - - - +63 Shilajit - - - - - +64 Katurya - - - - - +65 Phalatraya - - - - - +66 Jirne Bhojana - - - + - -Table No14: Showing Aharaja Pathyapathya:SlNo. Ahara Varga Pathya Apathya 1 Suka Dhanya Puran Shali, Kodrava, Shyyamak, Godhum, Naveen (Cerel Grain) Yava, Priyangu, Laja, Nivara, Dhanya (Shali) Koradushaka, Jurna, Prashatika, Kanguni. 2 Shami Mudga, Rajamasha, Kulattha, Masha, Til Dhanya Chanaka, Masur, Adhaki, (Pulses) Makusthaka. 3 Shaka Varga Patol, Patrashaka, Shigru, Vruntaka, Kanda Shaka, (Vegetables) Katutika, Rasatmak etc. Vastuka, Madhura, Trapusha Vartaka, Evaruka, Adraka, Rasatmak Mulaka, Surasa, Grajjan. 4 Phala Varga Kapittha, Jambu, Amaliki, Ela, Madhura Phala (Fruits) Bibhitaki, Haritaki, Maricha, Pippali, Evaluation of Efficacy of Mushkakadi Yoga 73
    • Disease review Erand Karkati, Ankola, Naranga, Bilvaphala. 5 Drava Varga Honey, Takra, Ushnajala, Tila & Milk Preparations Sarshapa Tail, Ashava Arista, (Dugdha,Dhadhi, Surasava, Jeerna Madya Sarpi) Ikshuvikara 6 Mamsa Varga Rohit Matsya Aanupa, Audaka, Gramya Mamsa SevanaPATHYA – APATHYA VIHARTable No15: Showing Viharaja Pathyapathya: Pathya Apathya Ushnodaka Sheetal Jala Sevan Sevana Diwaswapna Ratri Jagarana Avyavaya Bhraman Avyayam Rohan Ati Ashana Upavasa Sukha ShaiyaTable No16: Showing Manasika Pathyapathya Pathya Apathya Shoka Nitya Harsha Chinta Achintana Bhaya MansoNivrutti Evaluation of Efficacy of Mushkakadi Yoga 74
    • Drug reviewDrug review: Mushkakadi Yoga has been described by Sushruta in Sutrasthana.Though Vaghbhatta has also mentioned Mushkakadi Yoga but this clinicaltrial drug has been prepared as described by Sushruta. The drugs of this yogaare mainly Ushna viryatamaka with Katu vipaka and predominantly Ushnaand Tikta gunas and possessing lekhana, bhedana etc properties. By virtue ofthese properties, this yoga is Kapha-vatashamaka as well as Medoghna.Table No: 17: Showing the components of Mushkakadi Yoga Ingridient Botanical Name Quantity Mushkaka Schrebera swietniodes 1 part Palasha Butea monosperma 1 part Dhava Anogeissus latifolia 1 part Chitrak Plumbago zeylanica 1 part Madanphala Randia spinosa 1 part Kutaja Holarrhena antidysentrica 1 part Shimshapa Dalbergia sissoo 1 part Vajravruksha Euphorbia nerifolia 1 part Haritaki Terminalia chebula 1 part Vibhitaki Terminalia bellirica 1 part Amalaki Emblica officinalis 1 part Evaluation of Efficacy of Mushkakadi Yoga 75
    • Table No 18: Showing properties of Ingriedents constituting Mushkakadi Yoga.SL.No Sans Name Latin Name Gana Kula Rasa Guna Virya Vipaka 1 Mushkaka Schrebera Mshkakadi Shimbi(Legu Katu Laghu Ushna Katu sweitniodes minosae Tikta 2 Palasha Butea Mushkakadi,,Nyagrodha Shimbi(Legu Katu,Tikta Laghu Ushna Katu monospera di,Ambasthadi minosae) Kashaya Rooksha 3 Dhava Anogeissus Salsaradi,Mushkakadi Haritaki(Com Kashaya Laghu Sheita Katu latifolia Asanadi(Va) bretacea ) Rooksha 4 Chitrak Plumbago Dipaniya,Lekhaniya, Chitraka Katu Laghu Ushna Katu Zeylanica Thuptighna,bhedaniya (Plumba- Rooksha (cha),Pippalyadi,Varuna -ginaceae) Teeksha di(Su), Panchkola ( B.P )5 Madanphala Randiaspinosa Vamana,Phalini(cha),Ur Manjishta Kashaya Laghu Ushna Katu dhvabhagahara,Aragawa (Rubiaceace) Madhura Rooksha Prabhava ohadi,Mushkakadi(Su ) Tikta,Katu Vamana6 Kutaja Holarrhena Arshoghna,Kandughna, Kutaja Tikta Laghu Sheeta Katu Antidysentrica Vamana,Stanyasodhana (Apocyn- Kashaya Rooksha (ch),Pippalyadi, -aceae) Haridradi ( Su )7 Shimshapa Dalbergia Kashayaskandha,Asavyo Shimbi Kashaya Laghu Ushna Katu Sissoo nisara (Ch) ( Legumin- Katu Rooksha Salsaradi -osae ) Tikta Mushkakadi ( Su )8 Vajravruksha Euphoria Virechana,Shatashodana Eranda Katu Laghu Ushna Katu neripholia Vruksha(Sheerashrya) <Euphorb- Teekshna <cha>,Adhobhaghar, -iaceae> Syainadi < Su > 76
    • 9 Haritaki Terminalia Triphala,Amalakyadi Haritaki Kashaya Laghu Ushna Madhura chebula (Su),Parushkadi,Preyasth (Combretacea Pradhana Rooksha apana,Jwaraghna,Kustha e) Lavana jhna ( Ch ) Varjit10 Vibhitaki Terminalia Jwarahara,Virechanopag Combretacea Kashaya Laghu Ushna Madhura bellirica a(Ch),Triphala,Mustadi, e Rooksha ( Su )11 Amalaki Emblica Vayasthapana Eranda Pancharasa Guru Sheeta Madhura officinalis Virechanopaga ( Ch ) (Euphorbia- Lavanarahi Rooksha Triphala -ceae ) ta,Amlapra Sheeta Parushkadi ( Su ) dhan 77
    • Table No: 19: Showing Dosha and Roga Prabhava, Chemical Composition and action of trial drugsSr.No Sans Name Dosha Prabhava Roga Prabhava Karma Chemical Compound1 Mushkaka Kaphavatashamaka Medovriddhinashak Deepana. Lekhan Tannin2 Palasha Kaphavata Mutravarodha,Udara,Arsha,Netraroga,Krimi Deepana,Grahi,Ukhana, Kinotannic Shamaka Dhwajbhanga,Pradara,Apasamara,Jwara Stanbhana acid,Gallidacid, Rasayana,Kustha Bhedama,Balaya,Vishaghna Alkalord,Palasonin, Involatileoil3 Dhava Kaphapitta Kshata,Vrana,Shotha,Atisara,Pravahika, Raktarodhaka,Vranaropana Tannin Shamaka Raktarsha,Raktapitta,Prameha,Kustha ,Sothahara,Stambana Soditsthapana,Vishaghna Mutrasangrahaniya Kusthaghna4 Chitraka Kaphavata- Shalyzada,Sotha,Svitra Lekhaniya,Visphotjanana Plumbagin -shamaka Kustha,Aamvata,Vata- Uttejaka<alpa matra> Sucrose, Pittavardhaka -vyadhi,Agnimandya, Madaka(ati matra> Fructose, Ajirna,Udarashoola,Grahani,Arsha,Krimi, Deepana,Pachana,Pittasa- Protease, Yakruta,Pliha,Guda Sotha Kasa, JirnaPrati- -raka,Grahi,Sothahara, Invertase syaya,Rajorodha,Makkalshoola,Dhwajbhanga, Kanthya,Jananendriya Jirna&VishamaJwara,Rasayana(Su&Va) Uttejaka Swedajanana5 Madanphala Kapha Amavata,Vidradhi,Vrana,Udarashoola,Vibhandha, Sothahara,Vedanasthapana Saponin, Vata shamaka Gulma,Krimi,Pravahika sotha, Raktavikara, Kasa, Vranashodaka,Vamaka, Trytprine, Swasa,Kastartava,KastaprasavaKustha,Jwara, Vata anuloman,Krimighna Tannin,Protein Medoroga Grahi,Raktashodaka,Ka- Sugar Carbo- phanisaraka,Artavajanana, -hydrate,Aud 78
    • Swedajanana,Kusthaghna Randia oil Jwaraghna,Vishaghna, Lekhan6 Kutaja Kaphapitta Vrana,Agnimandya,Ahsara,Pravahika, Vranaropana,Vamaka, Conessin(bark) shamaka Jwaratisara, Arsha,Udarashoola,Krinni,Vatarakta, Deepana,Stambhana, Foul smelling Kustha,Raktapitta,JwaraAtisthoolta Sangrahaniya,Upashosha- Oil from seeds -ka,Lekhana7 Shimshapa Tridosha Netraroga,Krimmi, Vramasodhana,Krimighna Tannin shamaka Kustha,Gridhrasi,Prava- Chaksushya,Stambhana, Alkaloids -hika,Ahsara,Agniman- Deepana,Anulomana,Soth- Leight brown -dya,Raktarsha,Hikka, -ahara,Raktashedalea,Gar- Coloured fixed Swasa,Phiranga,Upada- -bhasaya sankochaka Oil -nsha,Rajorodha,Rakta- Astavajanana,Mutrala, -pradara,Puyameha,Vas- Lekhana -ameha,Jwara,Medoroga8 Vajravruksha Kapha Karnashoola,Vatavyadhi Vedanasthapana,Lekhana Euphorbon,Rubber vathara Dantashoola,Kustha,Kl- Raktimajanaka,Rechana, Calcium maleate -aivya,Bhagandara,Arsha Virechana,Raktashodhaka Milky extract Jwara,Gulima,Vakruta- Sothahara,Kaphanisareka -pliha vriddhi,Pandu, Vishaghna Madhumeha,Unmada, Upadansha,Vatarakta, Kasa,Swasa9 Haritaki Tridoshahara Netrabhishyanda,Vrana,Indriyadonrbalya, Sothahara,Vedanasthapana Chebulagic acid Predominantly Vatavyadhi,Agnimandya,Shoola,Gulma, Vrama sodhana,Vramaro- (fruits) Vatahara Udararoga,Arsha,Kamla,Grahini,Krimi, -pana,Medhya,Indriya Chebulinic acid Srotasodhana,Hridya, dourbalya,Vatarakta shakti vardhaka,Dipana, Conlagin Kasa,Swarabheda,Shukrameha,Swetapradara, Pachana,Krimighna Amino acid Ashamari,Mutrakruccha,Prameha,Vishama & Hridya,Shoditasthapana, Phosphonc acid, Jirna Jwara Vrushya,Mutrala,Kusth- Succinic acid, -aghna,Rasayana Quinick acid Yellowish oil(seed) 79
    • 10 Vibhitaki Tridoshara Kustha,Agnimandeya, Sothahara,Vedanasthapana Tannin,B-setosterol Predominantly Palitya,Kasa,Swasa,Prati- Raktastambhana,Krishikar- Gallic acid,elagic Kaphahara -syaya,Swarabhanga, -ana,Dipana,Anuloniana, Acid,chebulagic Abhisyanda,Vatavyadhi, Krimighna,Trishnanigra- acid Anidra,Agnimandya, hana,Chardinigrahana, Manmitol Glucose, Trishna,Chardi,Arsha, Vajikarana,Chaksushya, Galactose,Fructose Krimi,Klaivya,Jwara, Dhatuvardhuka Seeds-bright Netraroga yellow Coloured fixed oil11 Amalaki Tridoshara Mastiskadourbalya,Drish- Dahashamalca,chaksushya Vitamin C,gallic Predominantly -tmandya,Indriyadaurbalya Keshya,Medhya,Indriya- Acid,Tannic acid, pittashamaka Aruchi,Agnimandya,Yak- -shakti,Vardhaka,Rechana, Sugar,albumin,cell- -rutavikara,Amlapitta,Pari- Dipana,Anulanana,Stambha- -ulose,calcium, -naimashoola,Udavrata, -na,Yakrutauttejaka,Hridya, Nicotinic acid, Udara,Raktapitta,Hridaro- Vrishya,Garbhasthapana, Elagic acid, -ga,Yakshna,Swasa,Prad- Mutrala,Rasayana Seeds-brownish -ara,Sukrameha,Mutrakru- Yellow coloured -ccha,Kustha,Sotha,Jirna Nonvolatile oil Jwara 80
    • Clinical study METHODOLOGYMaterials:Source of Dataa) Patients are selected from the OPD and IPD of Kayachikitsa dept. Post Graduate Studies and Research, DGMAMC and Hospital, Gadag.b) Literary – Literary aspect of study is collected from classical Ayurvedic and Modern texts and updated recent Medical Journals.c) Therapy – Shamana Chikitsa Yoga – Mushkakadi Yogad) Composition of Mushkakadi Yoga : Ingridient Botanical Name Quantity Mushkaka Schrebera swietniodes 1 part Palasha Butea monosperma 1 part Dhava Anogeissus latifolia 1 part Chitrak Plumbago zeylanica 1 part Madanphala Randia spinosa 1 part Kutaja Holarrhena antidysentrica 1 part Shimshapa Dalbergia sissoo 1 part Vajravruksha Euphorbia nerifolia 1 part Haritaki Terminalia chebula 1 part Vibhitaki Terminalia bellirica 1 part Amalaki Emblica officinalis 1 partCollection and Preparation of Medicine:- All the herbs are well identified and collected from local area and market. Allare taken in powder form in equal properties and the mixture is formulated intogranules. All are taken in powder form in equal quantity and the mixture is mixedwith 10% starch formation. The product is kept in the mass mixture device, which Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 80
    • Clinical studyresults in the formation of snug. This snug is then kept in a drier and thereafter, intoan oficillator granular. This ultimately results in the formation of granules. As thesegranules are easily dissolvable in lukewarm water, the patient feels more comfortablein consuming the medicine.Clinical Study: Research can be defined as a scientific study done for the purpose ofestablishing new facts or discard the old facts or modify the present facts or prove theold Ayurvedic facts on the basis of systematic scientific research methodology ,without altering its basic principles .Research Approach: The objective is to. “Evaluate the efficacy of MushkakfadiYoga in Sthoulya obesity. The efficacy can be determined by finding out thedifference between the baseline data and after follow up data.Study Design: - The study design set for the present study is “Randomised clinicalstudy”. The study was done in single group.Selection Criteria:Inclusion criteria: Patients between 20-60 years irrespective of sex 10 % excess weight than the average weight in relation to height Including all clinical signs and symptoms of SthoulyaExclusion criteria: Patients with secondary pathologies like Diabetes Mellitus etc . Obesity due to hormonal disturbance Complicated obesity with other systematic disordersSample Size: Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 81
    • Clinical study The sample size for the present study consists of 30 patients with Sthoulyadisease.Duration of Study: 60 days Follow-up- 30 daysData Collection: Patients selected were thoroughly examined by both subjective and objectiveparameters. Detailed history and physical examination findings were noted.Laboratory investigations were done to exclude or include the concerned sample inthe study.Mushkakadi Yoga : This yoga has been quoted by Sushruta in 38th chapter of sutrasthana .Thedose selected is 3 gm / day , divided in three doses of 1 gm each , distanced 8 hourlyTreatment Schedule : Posology – 3 gm / day, divided in 3 doses of 1 gm each , distanced 8 hourly Duration - 60 days Followup-30 daysDiet and exercise: Patients are advised to adhere to the Pathya Ahara and Vihara preparedaccording to principles of Ayurveda and caloric value calculations and food items andcaloric demand of the individual. Besides this patients are advised to do exercise oryogasana and walking for at least 30 minutes a day. The body circumference was measured at various parts like chest, abdomen,hip, with the help of standard measuring tape made of synthetic material. To measurethe body weight, a standard weighing machine was used. To measure the height, a Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 82
    • Clinical studyheight chart was posted on the wall of the O.P.D, Kayachikitsa deptt., with readingsboth in meters and feet. Vernier caliper was used for measuring skin fold thickness.Materials for laboratory Investigation: Table No.20: Showing the Materials used for Lipid Profile: Test Name of the reagent HDL Auto-span liquid Gold HDL cholesterol kit LDL Auto-span liquid Gold LDL – kit S. Triglycerides Auto-span liquid Gold Triglycerides kit S. Cholesterol Auto-span liquid Gold Cholesterol – kitMethod of Assessment of treatment : Subjective and objective parameters are taken for the assessment of results.Separate grading has been given for subjective parameters that include the followingChala sphika stana udara GradeAbsence of chalatva 0Little visible movement (in these areas) after fast movement 1Little visible movement (in the areas) even after moderate movement 2Movement (in the areas) after mild movement 3Movement (in the areas) even after changing posture 4KruchyayvataNo problem in sexual intercourse 0Occasionally problem of erectile dysfunction 1Frequently having the problem of erectile dysfunction 2No desire of sexual activity 3Can not perform sexual activity 4Dourbalya:Can do routine exercise 0Can do moderate exercise without difficulty 1Can do only mild exercise 2Can do mild exercise with very difficulty 3 Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 83
    • Clinical studyCannot do even mild exercise 4Swedadikyata:Sweating after heavy work and fast movement Or in hot season 0Profuse sweating after moderate work and movement 1Sweating after little work and movement 2Profuse sweating after little work and movement 3Profuse sweating without any exercise 4Daurgandhyata:Absence of bad smell 0Occasional bad smell from the body, which removed After bathing 1Persistent bad smell limited to close areas difficulty to Suppress with deodorants 2Persistent bad smell felt from long distance and is not Suppressed by deodorants 3Persistent bad smell felt from long distance even Intolerable to the patient himself 4KshudraswasaNo Dyspnoea 0Dyspnoea in resting condition 1Dyspnoea after little work but relieved later and beyond tolerances 2Dyspnoea after moderate work but relieved later and beyond tolerances 3Dyspnoea after heavy work but relieved soon and up to tolerance 4Atinidra:No day sleep can get up early, night sleep<6 hrs. 0Can avoid day sleep easily bit drowsy, night sleep<7-8 hrs 1Cannot avoid day sleep drowsy, day sleep 1-2 hrs and night sleep 8-9 hrs 2Always drowsy, sleepy, day sleep 3-4 hrs and night sleep 9-10 hrs 3Sleep while sitting itself, day sleep 5-6 hrs and night sleep>10 hrs 4Atikshudha: Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 84
    • Clinical studyAtikshudha was decided on the basis of ruchi, abhyavaharana shakti and jarana shakti.A) Abhyavaharana Shakti:Person taking food in less quantity once in a day 0Person taking food in less quantity twice in a day 1Person taking food in moderate quantity twice in a day 2Person taking food in normal quantity twice a day 3Taking food in excessive quantity twice or thrice 4B) Jarana Shakti:According to presence of jirna aahara lakshana (M.N.6/24), utsahaha, laghuta, udgarshuddhi, kshudha, trushna pravrutti yathochita malotsarga.Presence of one symptom after 6 hours 0Presence of two symptoms after 6 hours 1Presence of three symptoms after 5 hours 2Presence of four symptoms after 5 hours 3Presence of all symptoms after 4 hours 4C) Ruchi:Totally unwilling for meal 0Unwilling for food, but could take the meal 1Willing towards only most liking food, and not to other 2Willing towards some specific aahara or rasa visesha 3Equal willing towards all the bhojya padartha 4Ati Pipasa:Normal thirst 0Upto1 liter excess intake of water 11 to 2 liters excess intake of water 22 to 3 liters excess intake of water 3More than 3 liters excess intake of water 4OBJECTIVE CRITERIA:Weight:Grade -0 Above 3 kg Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 85
    • Clinical studyGrade –1 Up to 3 kgGrade –2 Up to 2 kgGrade –3 Up to 1 kgGrade –4 no change (Basic)B.M.I.:Grade –0 Above 1.20Grade –1 .90 - 1.19Grade –2 .60 - .89Grade –3 .30 - .59Grade –4 .00 - .29In general body circumference for chest, abdomen, waist, hip, waist and hip ratio:Grade –0 Above 1.60Grade –1 1.20 – 1.59Grade –2 .80 – 1.19Grade –3 .40 - .79Grade –4 .00 – 39Overall assessment: • Good respond - > 70% in both subjective and objective parameters • Moderate respond – 50-70% in both subjective and objective parameters • Mild respond -30-50% in both subjective and objective parameters • No respond - < 30% in both subjective and objective parameters. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 86
    • Observations and ResultsObservation and Results: In the following clinical trial total 25 patients were included. Observationswere done before the treatment, during the treatment and after the treatment. The following pages consists the observations recorded and the results of thetrial drug on the patients along with the statistical analysis of the result of the drug onindividual subjective as well as objective parameter. Table No. –21: Showing the incidence of age in 25 patients Age group Total no. of Patients percentage20-29 yrs 09 36%30-39 yrs. 08 32%40-49 yrs 05 20%50-60 yrs. 03 12%Total 25 Age wise distribution of all twenty five patients shows that in age group of 20-29 years 09 (36.0%) patients were reported, in age group of 30-39 years 08 (32.0%)patients were undergone the treatment and in age group of 40-49 years 05 (20.0%)patient were undergone treatment and in age group of 50-60 years 03 (12.0%) werereported for the treatment.Figure-1 Showing age wise distribution of total 25 patients: 10 8 20-29 30-39 6 40-49 4 50-60 2 0 Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 87
    • Observations and ResultsTable-22; Showing sex wise distribution of total 25 patients with percentage: Sex Total no. of Patients PercentageMale 12 48%Female 13 52%Total 25 In the present study 12 (48%) of the patients were male and 13 (52%) werefemale.Figure-2 Showing sex wise distribution of total 25 patients: 13 12.8 12.6 Male 12.4 Female 12.2 12 11.8 11.6 11.4Table-23: Showing religion wise distribution of total 25 patients with percentage: Religion Total no. of Patients PercentageHindu 15 60%Muslim 06 24%Christian 04 16%Others 00 00Total 25 In this study 15 (60%) of the patients belongs to Hindu category, 6(24%)belongs to Muslim category and 04 (16%) belongs to Christian community. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 88
    • Observations and ResultsFigure 3:Showing religion wise distribution of 25 patients 16 14 12 Hindu 10 Muslim Christian 8 Others 6 4 2 0Table-24: Showing occupation wise distribution of total 25 patients withpercentage: Occupation Total no. of Patients PercentageSedentary 15 60%Active 10 40%Labour 0 0Total 25 In the occupation wise distribution 15 (60%) of the patients had sedentary lifestyle, and 10(40%) of the patients had active occupation..Figure 4: Showing occupation wise distribution of 25 patients: 16 14 12 Sedentary 10 Active 8 Labour 6 4 2 0 Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 89
    • Observations and ResultsTable-25: Showing marital status wise distribution of 25 patients with percentage: Marital Status Total no. of Patients PercentageUnmarried 08 32%Married 17 68%Total 25 Out of 25 subjects 8(32%) were unmarried and17 (68%) are married.Figure-05: Showing marital status wise distribution of 25 patients 18 16 14 12 Married 10 Unmarried 8 6 4 2 0 Table26: Showing intake rasa predominance wise distribution of 25 patients: Rasa predominance Total no. Of Patients PercentageMadhura 12 48%Amala 05 20%Lavana 0 0Katu 08 32%Tikta 0 0Kashaya 0 0 In this study maximum 12(48%) patients have taken Madhura Rasapredominantly in their diet, followed by 08 (32%) Katu Rasa, 5(20%) Amla Rasawhile none of the patient had lavana, tikta, kashaya rasa as the predominant rasa in thediet. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 90
    • Observations and Results Figure-6: Showing intake rasa wise distribution of 25 patients 12 10 Madhura 8 Amla Lavana 6 Katu Tikta 4 Kashaya 2 0Table-27: Showing nidra wise distribution of total 25 patients with percentage: Nidra Total no. Of Patients PercentageSukha 0 0Alpa 0 0Ati 13 52%Vishama 12 48%Diwaswapna 8 32% In this study 13(52%) patients were having Ati nidra, 12(48%) patientsVishama nidra while no patient was experiencing Sukha or Alpa nidra. 8(32%) werehaving the habit of Diwaswapana. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 91
    • Observations and ResultsFigure-7 Showing nidra wise distribution of total 25 patients 14 12 Sukha 10 Alpa 8 Ati Vishama 6 Diwaswapna 4 2 0Table-28: Showing distribution of 25 patients according to Vyasana Vyasana Total no. of Patients PercentageTea/Coffee 20 80%Alcohol 6 24%Smoking 10 40%Tobacco 7 28% The present study shows that 20(80%) patients were having addiction oftea/coffee, 6(24%) patients of alcohol, 10(40%) patients of smoking and 7(28%)patients were addicted to tobacco chewing.Figure-08: Showing Vyasana wise distribution of 25 patients 20 18 16 Alcohol 14 Tea/Coffee 12 Tobacco 10 Smoking 8 6 4 2 0 Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 92
    • Observations and ResultsTable29: Showing diet wise distribution of total 25 patients with percentage: Diet Total no. Of Patients PercentageVegetarian 7 28%Mixed 18 72%Total 25 In the present study 7(28%) patients were vegetarian and 18(72%) werehaving mixed dietFigure-09: Showing diet wise distribution of total distribution of total 25 patients 18 16 14 12 Vegetarian 10 Mixed 8 6 4 2 0Table-30: Showing shareera prakriti wise distribution of total 25 patients: Shareera Prakriti Total no. of Patients PercentageVP 05 20%VK 09 36%PK 11 44%Total 25 The above table shows 5(20%) of the patients had vatapitta prakriti, 9(36%) ofthe patients had vatakapha prakriti and 11 (44%) of the patients had pittakaphaprakriti Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 93
    • Observations and ResultsFigure-10 Showing shareera prakriti wise distribution of 25 patients. 12 10 8 Vatapitta Vatakapha 6 Pittakapha 4 2 0Table-31: Showing sara wise distribution of total 25 patients with percentage: Sara Total no. of Patients PercentagePravara 8 32%Madhyama 15 60%Avara 2 8% The above table shows 8 (32%) of the patients had Pravara Sara, 15 (60%) ofthe patients had Madhyama Sara, 2 (8%) of the patients had AvaraSara.Figure-11 Showing sara wise distribution of 25 patients 16 14 12 Pravara 10 Madhyama 8 Avara 6 4 2 0 Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 94
    • Observations and ResultsTable-32: Showing samhanana wise distribution of total 25 patients Samhanana Total no. of Patients PercentagePravara 2 8%Madhyama 19 76%Avara 4 16%Total 25 The above table shows 2(8%) of the patients had Pravara Samhanana,19(76%) of the patients had Madhyama Samhanana and 4(16%) had AvaraSamhanana.Figure-12 Showing samhanana wise distribution of total 25 patients 20 18 16 14 Pravara 12 Madhyama 10 Avara 8 6 4 2 0Table-33: Showing satwa wise distribution of total 25 patients with percentage: Satwa Total no. of Patients PercentagePravara 3 12%Madhyama 9 36%Avara 13 52%Total 25 The above table shows that 3(12%) patients have Pravara satwa, 9(36%)patients have Madhyama satwa and 13(52%) patients were having Avara satwa. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 95
    • Observations and ResultsFigure-13 Showing satwa wise distribution of total 25 patients 14 12 10 Pravara 8 Madhyama Avara 6 4 2 0Table-34: Showing vyayama shakti wise distribution of total 25 patients: Vyayama shakti Total no. of Patients PercentagePravara 2 8%Madhyama 11 44%Avara 12 48%Total 25 The above table shows 12(48%) of the patients had Avara Vyayamashakti, 11(44%) of the patients had Madhyama Vayamashakti and 02 (8%) of the patients hadPravaraVyayamashakti.Figure-14 Showing vyayama shakti wise distribution of total 25 patients 12 10 8 Pravara Madhyama 6 avara 4 2 0 Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 96
    • Observations and ResultsTable-35: Showing pramana wise distribution of total 25 patients: Pramana Total no. of Patients PercentagePravara 3 12%Madhyama 20 80%Avara 2 8%Total 25 The above table shows 3(12%) of the patients have Pravara pramana, 20(80%)of the patients had Madhyama Pramana and 2(8%) of the patients had Avara PramanaFigure-15 Showing pramana wise distribution of total 25 patients 20 18 16 14 Pravara 12 Madhyama 10 avara 8 6 4 2 0Table-36-A Showing Abhyvarana Shakti (AS) wise distribution of total 25patients: A) Abhyvarana Total no. of Patients PercentagePravara 8 32%Madhyama 15 60%Avara 2 8%Total 25 The above table shows that 8(32%) of the patients had Pravara AbhyvaranaShakti, 15(60%) of the patients had Madhyama Abhyvarana Shakti and 2(8%) of thepatients had Avara Abhyvarana Shakti Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 97
    • Observations and ResultsFigure-16-A Showing Abhyvarana Shakti (AS) wise distribution of total 25patients 16 14 12 Pravara 10 Madhyama 8 Avara 6 4 2 0Table-36-B Showing Jarana Shakti (JS) wise distribution of 25 patients: B) Jarana Total no. of Patients PercentagePravara 5 20%Madhyama 17 68%Avara 3 12%Total 25 The above table shows that 5(20%) of the patients had Pravara Jarana Shakti,17(68%) of the patients had Madhyama Jarana Shakti and 3(12%) of the patients hadAvara Jarana Shakti.Figure-16-B Showing Jarana Shakti (JS) wise distribution of 25 patients: 18 16 14 12 Pravara 10 Madhyama 8 avara 6 4 2 0 Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 98
    • Observations and ResultsTable-37 Showing jatharagni bala wise distribution of total 25 patients: Jatharagni bala Total no. of Patients PercentageManda 0 0Teekshna 13 52%Vishama 12 48%Sama 0 0Total 25 The above table shows13 (52%) of the patients had Teekshna Agni, 12(48%)of the patients had Vishama Agni. Not even a single patient had either Manda orSama Agni.Figure-17 Showing jatharagni bala wise distribution of total 25 patients: 14 12 10 Manda Vishama 8 Teekshna 6 Sama 4 2 0 Table-38 Showing koshta wise distribution of total 30 patients withpercentage: Koshta Total no. of Patients PercentageKroora 9 36%Madhyama 0 0Mrudu 16 64%Total 25 Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya 99
    • Observations and Results The above table shows that 16(64%) of the patients had Mrudu Koshta,9(36%) of the patients had Kroora Koshta while none of the patients had MadhyamaKoshta.Figure-18 Showing koshta wise distribution of total l25 patients 20 15 Kroora Madhyama 10 Mrudu 5 0Table-39 Showing family history wise distribution of total 25 patients: Family history Total no. of Patients PercentageYes 10 40%No 15 60%Total 25 In this study 10(40%) of the patients had family history of Sthoulyawhile 15(60%) of the patients did not had family history of Sthoulya.Figure-19Showingfamilyhistorywisedistributionoftotal25patients: 15 Yes 10 No 5 0 Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya100
    • Observations and ResultsTable-40 Showing Vyayama wise distribution of total 25 patients: Vyayama Total no. of Patients PercentageNo 11 44%Occasionally 14 56%Everyday 0 0 25 In this study 11(44%) of the patients showed No Vyayama while 14(56%) ofthe patients showed Occasional Vyayama. None of the patient had the habit ofeveryday Vyayama.Figure-20 Showing Vyayama wise distribution of total 25 patients 14 12 10 No Vyayama 8 Occasionally Everyday 6 4 2 0 Table-41 Showing weight wise distribution of total 25 patients: Weight in Kg Total No. of patients Percentage70-75 1 4%76-80 6 24%81-85 13 52%86-90 5 20% In the present study, 13(52%) of the patients were in the weight range of 81-85, 6(24%) in the weight range of 76-80, 5(20%) in the weight range of 86-90 and1(4%) in the range of 70-75 Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya101
    • Observations and ResultsFigure-21: Showing Weight wise distribution of total 25 patients 14 12 10 70-75 76-80 8 81-85 6 86-90 4 2 0Table-42 Showing the incidence of BMI in 25 patients: BMI No. of patients percentage 30.1-32 8 32% 32.1-34 3 12% 34.1-36 5 20% 36.1-38 6 24% 38.1-40 2 8% In this study 8(32%) of the patients were in the BMI range of 30.1-32, 6(24%)were in the range of 36.1-38, 5(20%) in the BMI range of 34.1-36, 3(12%) in the BMIrange of 32.1-34, and 2(8%) in the range 38.1-40.Figure-22 Showing the incidence of BMI in 25 patients: 8 7 6 30.1-32 5 32.1-34 34.1-36 4 36.1-38 3 38.1-40 2 1 0 Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya102
    • Observations and ResultsTable-43 Showing the incidence of chief complaints of sthoulya in 25 patients: Symptoms Total no. of Patients PercentageKshudaatimatra 25 100%Pipasaatiyogasha 25 100%Swedadikhayata 23 92%Dourgandhaya 23 92%Kruchvyavta 06 24%Gatrasada 12 48%Angagaurava 22 88%Nidradikyata 14 56%Kshudraswasa 19 76% The present study revealed that 5(100%) of the patients had thecomplaint of Kshudatimatra, 25 (100%) were having the complaint ofPipasaatiyogasha, 23(92%) of Swedadikyata, 23(92%) of Dourgandhaya, 06(24%) ofKruchvyavta, 12(48%) of Gatrasada, 22(88%) of Angagaurava, 14(56%) ofNidradikyata and 19(76%) were having the complaint of Kshudraswasa.Figure-23 Showing symptoms wise distribution of total 25 patients: 25 Kshudatimatra 20 Pipasatiyogasha Swedadikyata 15 Dourgandhya Kruchvyavata Gatrasada 10 Angagaurava Nidradikyata 5 Kshudraswasa 0 Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya103
    • Observations and ResultsTable-44 Showing associated complaints wise distribution of total 25 patients: Associated complaints Total no. of Patients PercentageAruchi 03 12%Kriya asamartata 16 64%Shareera gauravatava 19 76%Talu shosha 25 100%Alasya 21 84%Dourbalya 24 96%Vyayama asamartata 24 96% In this study, the associated complaint of Aruchi was present in 03(12%) ofthe patients, that of Kriya asamartata in 16(64%) of the patients, Shareera gauravatavain 19(765) of the patients, Talu shosha in 25(100%) of the patients,Alasya in 21(84%)of the patients, Dourbalya in 24(96%) of the patients and Vyayama asamartata wasreported by 24(96%) of the patients Figure-24:Showing Associated complaint wise distribution of 25 patients. 25 20 Aruchi Kriyaasartata 15 Shareera gauravatava Talu sosha Alasya 10 Dourbalya Vyayama asamartata 5 0Table No.45 Showing the incidence of type of obesity in total patients:Type of Obesity Total no. of patients PercentageAndroid 13 48%Gynoid 12 52%Total 25 Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya104
    • Observations and ResultsFigure No. 25 Showing the incidence of type of obesity in total patients 14 12 10 Android 8 Gynoid 6 4 2 0 In this study, the android obesity was present in 13(52%) of the patients andthe gynoid obesity was present in 12(48%) patients. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya105
    • Observations and ResultsResults: The study was conducted on 25 patients and the results were taken afterconsidering subjective and objective parameters before and after treatment. Theresults are as follows: Sthana chalatwa, Udara chalatwa and Sphika chalatwa all have shownmore than 50% relief with statistical t-values of 6, 5.33, 12.3 respectively, which allare highly significant (p<0.001). The parameter Kshudraswasa has shown 77.2% of relief and it is alsoshowing statistically highly significance (t=6.57). This parameter is considered inSthoulya mainly due to the excessive pressure exerted by the excess fat around thethorax and abdomen on the lungs, the primary organs of respiratory system. In severecases, Obesity may/can lead to a number of complications of the respiratorycomplications such as chronic bronchitis, Pickwickian syndrome, pulmonaryhypertension etc. In Atikshudha, 46% of the relief was observed. The value lies in a highlysignificant zone (t=13.9,p<0.001). Due to the obstruction of samana vata in theKoshta there is atisandukshana of the Koshtagata Agni, which leads to the earlydigestion of the consumed food, and thus the person craves for more food. The parameter Swedadhikya shows an improvement of 61.8% showingstatistically a significant value (t=2.52,p<. 01). Meda dhatu is the main dushyainvolved in the samprapti (pathogenesis) of Sthoulya. Sweda has been considered asthe mala of Meda dhatu. Meda dhatu and Kapha dosha, the main samprapti ghatakasof the disease, are having the vishyandi nature, which causes Alasya, a predisposingfactor for the absence of Vyayama leading to Sthoulya. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya106
    • Observations and Results Atipipasa is relieved by 46% and statistically showing significant level(t=2.3,p<. 05). The causative factor for the Atipipasa may be the excessive loss ofdrava dhatu due to Sweda adhikyata. Dourgandhaya has shown 77.8% relief, which shows a statisticallysignificant level (t=2.62,p<01). Dourgandhaya can be attributed to the fact that Swedaadhikyata is a chief complaint of Sthoulya and shareera dourgandhya is caused byexcessive sweat secretion. Atinidra showed the relief of 46.3% with a significant statistical value(t=4.6,p=<.001). Kapha is the main dosha involved in the samprapti of Sthoulya andits vruddhi is also responsible for Atinidra. Due to this increase in Kapha dosha (ashareera dosha) there is vitiation of Tamas guna (manshika dosha) leading to atinidraand tandra like symptoms. The parameter Kruchvyavyata showed the relief of 16.7%, which statisticallyis less significant (t=1, p<0.1). Men who are with overweight or obese are at increasedrisk of having Erectile Dysfunction (ED). Obesity decreases the blood flow to thepenis thereby causing sexual dysfunction. Recently the statistical data of a researchconducted by the Australian researchers on 1000 men to know the impact of Obesityon their reproductive function revealed that 80% of the impotent men are obese andobesity increases the risk of impotency in men by 30%. The parameter Dourbalya, showed a relief of 69.4% with a highly significantvalue (t=12.4, p<. 001). This symptom can be attributed to the fact that the vitiation ofMeda Dhatwagni leads to the malformation of the subsequent dhatus Among the 25 patients, the mean weight reduction was 1.86%, whichstatistically is highly significant (t=9.2, p<. 001). The mean reduction in BMI of the Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya107
    • Observations and Resultspatients was 0.68%, which though less in comparison to weight, is statistically highlysignificant (t=7.2, p<. 001). The mean difference in the abdominal circumference of the patients was2.52, which is statistically highly significant (t=12.6, p<. 001). The mean difference inthe chest circumference was 2.26, which also statistically holds high significance(t=10.66, p<. 001). The mean difference of the hip circumference was 2.3, which isstatistically highly significant (t=2.3, p<10.96). The mean difference in the hip-waist ratio was .019%, which also has a highstatistical value (t=4.96, p<. 001). The height-weight ratio shows a mean differenceof .092, which also is statistically highly significant (t=4.28, p<. 001). Amongst the serum lipid profile, the serum triglyceride level shows the meandifference of 18.7, which is highly statistically significant (t=7.9,p<. 001), while theserum cholesterol level shows the mean difference of 16.04 which is also highlysignificant (t=10.9,p<. 001) The HDL levels before and after the treatment shows the mean difference of0.2, which though low but is still statistically highly significant (t=3.33, p<. 001). TheLDL level shows a mean difference of 11.95 which is a highly significant valueaccording to statistics (t=10.3, p<. 001). VLDL levels of the 25 patients show a meandifference of 3.65, which is also statistically highly significant (t=7.45, p<. 001). In the overall assessment, among 25 patients, 4(16%) of the patients showedgood response, i.e. above 70% relief in signs and symptoms, 15(60%) of the patientsshowed moderate response, i.e. 50-70% relief in the signs and symptoms while6(24%) showed mild response, i.e. 30-50% relief in signs and symptoms. Thestatistical data shows that most of the subjective parameters show highly significance Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya108
    • Observations and Resultswhile all the objective parameters show highly significance values, when comparedwith those of before treatment.Table No. 46: Showing the individual study of the subjective parameters to showsignificance effect before and after the treatmentSlNo. Parameters Mean S.D. S.E. t-vaue p-vaue Remarks1 Chala sphika 0.72 0.60 0.12 6 P< .001 HS2 Chala shana 0.68 0.63 0.126 5.33 P< .001 HS3 Chala udara 1.16 0.47 0.094 12.3 P< .001 HS4 Kshudraswasa 0.92 0.70 0.14 6.57 P< .001 HS5 Atikshuda 1.28 0.46 .092 13.9 P< .001 HS6 Atipipasa 1.36 2.08 0.42 2.3 P< .05 S7 Swedadhikhya 1.44 2.06 0.412 2.52 P< .01 S8 Dourgandhya 1.48 2.06 0.142 2.62 P< .01 S9 Atinidra 0.72 0.68 0.14 4.6 P< .001 HS10 Kruchvyavyata 0.04 0.2 0.04 1 P< .1 LS11 Dourbalya 1.12 0.44 0.09 12.4 P< .001 HSTable No.47: Showing the individual study of the objective parameters to showsignificance effect before after the treatmentSl.No. Parameters Mean S.D. S.E. t-value p-value Remarks1 Weight(kg) 1.86 0.97 0.2 9.2 P<.001 HS2 Chest(cm0 2.26 1.06 0.212 10.66 P<.001 HS3 Hip(cm) 2.3 1.04 0.208 10.96 P<.001 HS4 Abdomen(cm) 2.52 0.99 0.2 12.6 P<.001 HS5 BMI 0.68 0.51 0.1 7.2 P<.001 HS6 Hip-Waist Ratio 0.019 0.009 .002 4.96 P<.001 HS7 Height-Weight 0.092 0.06 .01 4.28 P<.001 HS ratio Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya109
    • Observations and ResultsTable No.48: Showing the Statistical Analysis of Lipid profile:Sl.No. Parameter Mean SD SE t-value p-value Remarks1 Serum 18.7 11.83 2.37 7.9 <. 001 HS Triglycerides2 Serum 16.04 7.34 1.47 10.9 <. 001 HS cholesterol3 Serum HDL 0.2 0.30 0.06 3.33 <. 001 HS4 Serum LDL 11.95 5.8 1.16 10.3 <. 001 HS5 SerumVLDL 3.65 2.45 0.49 7.45 <. 001 HS Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya110
    • DiscussionDiscussion:Discussion part is divided into the following parts- • Discussion on Review of literature • Discussion on Materials and Methods • Discussion on Clinical study. • Discussion on ResultsReview of literature: This portion consists of two parts, i.e., disease review and drug review.Disease review consists of historical review, vyutpatti and nirukti of sthoulya.Besides, the nidana, poorvaroopa, samprapti, roopa etc of sthoulya as described inclassical Ayurvedic texts has also been elaborated. The disease Obesity along with itsetiology, pathogenesis, types, signs and symptoms, treatment and complications hasalso been described .In the drug review, the drugs used in the formulation ofMushkakadi yoga has been discussed. The action of every individual drug on thedoshas and their properties has been elaborated. Sthoulya is a disease basically caused due to the impairment of the Paka Kriyaand this impairment of Agni plays a vital role in the Samprapti (pathogenesis) of thedisease. Pranavayu, Samanavayu, and Kledaka kapha are the main factors responsiblefor the proper digestion process along with Pachaka pitta. Pachaka pitta beingdrava(liquid) in consistency acts as an Agneya guna pradhana basically because it isAgni Mahabhuta pradhana in composition and due to this property it not only digestsbut also is essential in the bifurcation of the sara and kitta parts of the ahara. According to Ayurveda, after the ingestion of food first of all Jathragni acts onthe food resulting in the formation of Ahara rasa and then subsequent Dhatwagnis acton this Ahara rasa and this Dhatu paka process results in the formation of three parts Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya111
    • Discussionviz., 1)sthoola bhaga, responsible for the formation of that concerned dhatu2)sookshma bhaga, responsible for the formation of poshaka amsha of the subsequentdhatu and 3) the kitta bhaga/mala. So when mamsa dhatawagni acts on mamsa dhatu, it results in the formationof poshaka meda dhatu on which meda dhatwagni acts resulting in the formation ofsthoola meda dhatu, as sthoola bhaga, poshaka asthi dhatu as sookshma part andsweda as the kitta/mala bhaga. According to modern science the digestion of fat startsin the duodenum and pancreatic lipase is the main enzyme involved thereafterresulting in the formation of free fatty acids and monoglycerides. In a nut shell, theAhara paka kriya(digestion) plays an important part in the pathogenesis of Sthoulyaand it is an established fact that Agni is the sole factor responsible for the Ahara pakakariya(digestion). Ayurveda considers Agni of three types namely, Jathragni, Dhatwagni,Bhootagni. Jathragni being the prime of them governs the Dhatwagnis, which are 7 innumber respective to the sapta dhatus. The hypo functioning of a particularDhatwagni leads to the vruddhi(increase) of the respective dhatu and kshaya of thesubsequent dhatus while the hyper functioning of a particular dhatu leads to thekshaya (decrease) of that respective dhatu. Thus the dysfunction of Agni is the maincause of all diseases and same is the case with Sthoulya. Proper dietary habits are the root of a healthy life. The main causes ofSthoulya are adhyasana and vishamashana. Similarly, sometimes luxury can prove tobe a curse in disguise as Sthoulya has luxurious life style and sedentary occupationalstatus as one of its main etiological factor. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya112
    • Discussion Apart from these dietic or habitual factors the other factor that AcharyaCharaka has described to be responsible for Stholya is the Beejaswabhavaja and evenChakrapani comments on it as “Ati sthoola matru pitru sonitha sukra sambhavat”Showing similar ideology, like Ayurveda, even modern science considers dietaryhabits (aharatamaka nidana), routinary habits (viharatamaka nidana) andpsychological factors (manasika nidana) as the etiological factors of Sthoulya. Even the modern science accepts the fact that genetic determinants can play amajor role in the pathogenesis of Obesity (Sthoulya). There are number of knowngenetic conditions, such as Prader-Willi syndrome and mutations in the leptin gene,which produce a syndrome complex associated with Obesity. However, suchconditions are rare and are unlikely to have a bearing on the causation of obesity ingeneral population. Leptin, a hormone produced by the adipose tissue acts on thehypothalamus to suppress appetite. In case of increased fat deposit, due to feed backmechanism, the serum leptin level keeps on rising and so is the fat deposition. Thusthis abnormality in genetic factors leads to Sthoulya. The impairment of Jathragni obviously leads to the Dhatwaagni impairment.In the case of Sthoulya the Medadhatwagni mandya leads to vruddhi of Meda dhatu,which according to modern science can be justified due to lack of hormone sensitivelipase. If obesity seems to be spreading like virus, that could be because it is.Researchers have proved scientifically that even a virus named Ad-36 can be a causeof the Obesity. Eating less and exercising more is not the right means to reduce yourweight because the problem may be in your gut. Recent studies have shown that obesepeople have more Firmicutes bacteria in their stomach and intestines while the normalweight people have more Bacteriodestes bacteria in their stomach and intestines. In Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya113
    • Discussionfact the implications of this study are huge; change the bacteria in your gut to changeyour body. Samprapati vigyana is essential for the comprehension of specific features orvyadhi ghatakas of a disease as well as for the purpose of chikitsa as the basis ofchikitsa according to Ayurveda is the Dosha –Dushya samurchana vighatana orSammprapati nasha. Kapha and Meda dhatu plays a vital role in the pathogenesis of the Sthoulyadisease and hence can be considered as the main dosha- dushya ghatakas involved inSthoulya .Due to avarana (obstruction) of the strotas by the meda dhatu, there isvruddhi of koshtagata vata (samana vata) which ultimately leads to theatisandukshana of the jathragni. The increased jathragni leads to the rapid digestion ofthe ingested food and leaves the person craving for food. The net result is that there isincreased intake of food and due to Meda atiupachaya the result is Sthoulya. Sthoulya is a Santarpanjanya vyadhi and the chikitsa recommended for it byAcharya Charaka is “Guru cha Aptarpana”. Along with kapha and meda which arethe main dosha and dushya involved in the pathogenesis of sthoulya, vata and agnialso plays a vital role and can be considered as the upadravakaras in a stholya rogi. Sothe chikitsa must be focused on alleviating the vata and kapha dosha, besides takingcare of the increased meda dhatu and impaired agni. Mushkakadi Yoga contains drugs, which are mainly ushna viryatamaka withkatu vipaka and predominantly ushna and tikta gunas and possessing lekhana,bhedana etc. properties. By virtue of these properties, this yoga is kapha-vatashamakaas well as medoghna.Materials and Methods:The material taken for the clinical study is as following: Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya114
    • Discussiona) Therapy- Shamana Chikitsab) Yoga- Mushkakadi Yoga The entire ingredient herbs were well identified and collected from local areaand market.Prepration of the medicine: All the ingredient drugs were well identified and collected from local area andmarket. All are taken in powder form in equal quantity and the mixture is mixed with10% starch formation. The product is kept in the mass mixture device, which resultsin the formation of snug. This snug is then kept in a drier and thereafter, into anoficillator granular. This ultimately results in the formation of granules. As thesegranules are easily dissolvable in lukewarm water, the patient feels more comfortablein consuming the medicine.Clinical study: The patients were selected from the OPD and IPD of Kayachikitsa dept. PostGraduate Studies and Research, DGMAMC and Hospital, Gadag. Patients of bothsexes were selected for the clinical study between the age group 20-60 years keepingin consideration the inclusive and exclusive criteria. In total, 25 patients were selected for the study. Patients were thoroughlyexamined by both subjective and parameters. Detailed history and physicalexamination findings were noted. Laboratory investigations were done to exclude orinclude the concerned sample in the study. The BMI/ Quetlet’s Index is a precise parameter to measure body fat and moreaccurately differentiate “Overweight” due to an increase in muscle mass from trueObesity. The other objective parameters taken were weight, body circumference ofchest, abdomen and hip, hip-waist ratio, height-weight ratio. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya115
    • Discussion Mushkakadi Yoga was advised to the patients in the following dose: 3gm/day, divided in 3 doses of 1 gm each with lukewarm water.The duration of the study was 60 days followed by a follow-up of 30 daysResults:Age: During the present study, 09(36%) of the patients belonged to the age group20-29, 07(32%) of the patients were belonging to the age group 30-39, 04(16%)patients belongs to the age group 40-49, 04(16%) of the patients belongs to the agegroup of 50-60. According to Ayurvedic concept, Bala awastha is the stage offormation of dhatus, Madhyama awastha is the stage of Paripurnata of the dhatus andthe Vruddha awastha is the stage of the catabolism (destruction) of the dhatus. Thepresent study indicates that a large percentage of the patients belong to the age groupof 20-29 and 30-39 while those in the elderly group shows a small percentage ofincidence of Sthoulya. According to the modern science the incidence of Obesity ismost common in the adolescents but due to the age restriction criteria of the clinicalstudy and the small sample size taken for the purpose of the study this fact cannot beconcluded.Sex: In the present study, 12(48%) of the patients were male while 13(52%) of thepatients were female. Though it is a well-known and scientifically proved fact that thefemale sex is more prone to this disease either due to the hormonal changes at thestage of menopause or due to their routinely /dietic (viharatamaka/aharatamaka)habits, but this fact can not be established in this study due to the small sample sizeand the occupational/economical status, i.e., the type of population attending the OPDor present in the IPD of the hospital. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya116
    • DiscussionReligion: Out of total 25 patients, 15(60%) were of Hindu community, 06(24%) were ofMuslim community and 04(16%) were of Christian community. But this is notsignificant for making any conclusion about the incidence of the disease in aparticular community, as the data is the representation of the population in and aroundGadag.Occupation: This study show that out of the total 25 patients, 15(60%) of the patients werebelonging to the sedentary life style, 10(40%) were having active life style while noneof the patient belongs to the labour class. This clearly indicates that not only thedietary habits but also the occupational status plays an important role in the incidenceof Sthoulya. This can be attributed to the fact that the occupational status of a persondetermines his/her life style. A person with a sedentary life style must be leading amore or less luxurious life without any sort of exercise or walking while a personbelonging to the labour class, who can’t afford this luxurious life and for whom“hand to mouth” is the order of the day; it is not at all possible to be sthoola. Thismay be called as the cruelty of the destiny but it’s a fact that no one can deny.Marital status: In the present study, out of the 25 patients 17(68%) were married and 08(32%)were unmarried. The sex related orientation of the disease has not been mentioned inany of the classical texts but marital status surely plays a role in the etio-pathogenesisof the disease. Researches have shown that married adults, particularly men, had highrates of overweight or obesity. But the relation between obesity and marital statusawaits further study. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya117
    • DiscussionIntake of predominant rasa: In the present study it was observed that out of 25 patients, 12(48%) of thepatients were having Madhura rasa pradhana diet, 08(32%) were having Katu rasapradhana diet and 05(20%) were habitual to Amla rasa pradhana diet. None of thepatients’ were having Lavana, Tikta, Kashaya rasa pradhana diet. Madhura rasa, Amlarasa, Lavana rasa are the rasas that leads to Kapha prakopa and the Kapha doshashares Ashrya-Ashrayi bhava with meda dhatu and these two being the mainsamprapti ghatakas of Sthoulya, it can easily be concluded that the maximumincidence of Sthoulya will be in the person taking Madhura rasa pradhana192diet whilethose habitual to Tikta, Katu or Kashaya rasa predominant diet will be least effected.Nidra: None of the patients was experiencing Sukha or Alpa nidra. 13(52%) of thepatients were having the tendency of Atinidra, 12(48%) were having the tendency ofVishama nidra.08 (32%) of the patients were habitual to Diwaswapna. Ati nidracauses Kapha vruddhi as does Diwaswapna, while vishama nidra is due to vata, whichis also involved in the pathogenesis of Sthoulya and hence it can be concluded thatmost of the subjects/patients belonged to this category.Vyasana: The present study shows that 20(80%) patients were having addiction oftea/coffee, 6(24%) patients of alcohol, 10(40%) patients of smoking and 7(28%)patients were addicted to tobacco chewing. Alcohol has a high cholesterol value andincreases the fat content of the body. Giving up of smoking induces a fall in energyexpenditure equal to 9Kcal/cigaratte and increase in food intake The average weightgain is 2.8 kg in males and 3.8 kg in females Nevertheless, the risk of smoking is so Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya118
    • Discussionsubstantial that a rise in weight of 1 kg would be required to negate the loss of givingup smoking 20 cigarettes/day.Diet: In the present study 7(28%) patients were vegetarian and 18(72%) werehaving mixed diet Most of the patients were taking Guru, Sheeta and Snigdha gunapradhana diet which are the predominant factors for Sthoulya. Dietary habits are ofprime importance in the pathogenesis of Sthoulya. Ayurvedic texts has clearlymentioned the role of Guru, Snigdha, Madhura, Sheeta pradhana diet as theetiological factor of Sthoulya193 and this fact can rightly be justified by the results ofthe present study.Prakruti: The study shows 5(20%) of the patients had vatapitta prakriti, 9(36%) of thepatients had vatakapha prakriti and 11 (44%) of the patients had pittakapha prakriti.The concept of Prakruti is very specific to Ayurveda, which unlike other medicalsciences takes into consideration, the Prakruti of a patient before deciding what isbeneficial and what is harmful for a particular patient. In general, the persons havingdwandaja prakruti are considered to be more prone of being diseased as compared tothose with ek doshaja or sama prakruti. Similarly, the chikitsa of a vyadhi in a patientwith duandaja prakruti is more difficult as compared to that of ekdoshaja or samaprakruti.Sara, Satwa and Samhanana: In the study, 8 (32%) of the patients had Pravara Sara, 15 (60%) of the patientshad Madhyama Sara, 2 8%) of the patients had AvaraSara. In the study, 2(8%) of thepatients had Pravara Samhanana, 19(76%) of the patients had Madhyama Samhananaand 4(16%) had Avara Samhanana. In the study, 3(12%) patients have Pravara satwa, Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya119
    • Discussion9(36%) patients have Madhyama satwa and 13(52%) patients were having Avarasatwa. Acharyas opines that a Sthoola person will have vishama samhanana due todisproportionate height and weight ratio. A Sthoola person will be havingalpa/madhyama bala predominantly and alpa/madhyama sara predominantly, due tointerrupted poshana(nourishment) of the dhatus which ultimately results in dhatuasamatava.Vyayama and Vyayama Shakti: In this study 11(44%) of the patients showed no Vyayama while 14(56%) ofthe patients showed occasional Vyayama. None of the patient had the habit ofeveryday Vyayama. The study shows 12(48%) of the patients had AvaraVyayamashakti, 11 (44%) of the patients had Madhyama Vayamashakti and 02 (8%)of the patients had Pravara Vyayamashakti. The diminished level of physical activityleads to impaired metabolism as the equilibrium between energy gained and energyexpenditure gets disturbed or in other words, the anabolic rate exceeds the catabolicrate. This leads to accumulation of fat in the body resulting in Sthoulya. As in asthoola person there is impairment in the dhatu-poshana process, the Vyayama-shaktilevel tends to be more on the Avara or Madhyama levels.Agni bala: In this study, 13 (52%) of the patients had Teekshna Agni, 12(48%) of thepatients had Vishama Agni. Not even a single patient had either Manda or Sama Agni.Agni plays an important role in the pathogenesis of Sthoulya. The obstruction of vatadue to strotorodha caused by increased kapha and meda leads to Teekshna Agni andas vata also gets involved; the incidence of Vishama Agni is also high in sthoulyapatients. Elevated serum leptin level, a hormone normally produced by adipose tissuethat acts at the level of hypothalamus to suppress the appetite causes increase in Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya120
    • Discussionhunger of the obese patients. Thus obesity may be taken as analogous to type2diabetes, where patients have large amounts of insulin in their blood but are unableto respond to it.Abhyavarana Shakti and Jarana Shakti: In this study, 8(32%) of the patients had Pravara Abhyvarana Shakti, 15(60%)of the patients had Madhyama Abhyvarana Shakti and 2(8%) of the patients hadAvara Abhyvarana Shakti In this study, 5(20%) of the patients had Pravara JaranaShakti, 17(68%) of the patients had Madhyama Jarana Shakti and 3(12%) of thepatients had Avara Jarana Shakti Abhyvarana Shakti refers to the appetite while theJarana Shakti refers to the digestive power. Due to atisandukshana of the koshtagataagni, the Abhyvarana Shakti as well as the Jarana Shakti lies mainly in Madhyamaand Pravara categories.Pramana: In this study, 3(12%) of the patients have Pravara pramana, 20(80%) of thepatients had Madhyama Pramana and 2(8%) of the patients had Avara Pramana.Though the incidence of Madhyamat pramana is at the maximum but not muchconclusion can be drawn from it due to a small sample size.Koshta: In this study, 16(64%) of the patients had Mrudu Koshta, 9(36%) of thepatients had Kroora Koshta while none of the patients had Madhyama Koshta. Themaximum patients were having Mrudu Koshta, this can be attributed to the fact thatAgni is mainly the teeksna agni and according to the dosha-agni-kostha sambandha,the maximum incidence of Mrudu Kostha can rightly be justified. The vitiation ofvata, due to the obstruction of the srotas, can be considered as the reason behind theincidence of Kroora Kostha in 9(36%) of the patients. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya121
    • DiscussionFamily history: `In this study 10(40%) of the patients had family history of Sthoulya while15(60%) of the patients did not had family history of Sthoulya. Acharya Charaka hasmentioned Beejadosha as an etiological factor of Sthoulya and the genetic andchromosomal abnormalities role in the pathogenesis of Obesity has also been provedby the modern scientists.Sthana chalatwa, Udara chalatwa and Sphika chalatwa: All these symptoms have shown 50% relief with highly significant levels.Sphika, stana, udara lambanam has been considered as lakshanas of Meda dhatuvruddhi194 and almost all of the patients were present with these lakshanas. Accordingto the distribution of body fat, it can be said that either there is storage of fat aroundthe hips and thighs region, giving a pear shaped appearance or there is storage of fatprimarily in the abdomen, producing an apple like appearance. The former is knownas gynoid obesity and is more characteristic of women and the latter is known asandroid obesity which is found in both the sexes. Thus, both Ayurveda and modernscience accepts the distribution of excessive fat in these specific regions and theobservations of this study justify this fact.Kshudraswasa: Kshudraswasa as a chief complaint was present in 76% of the patients and therelief percentage was 77.2%, which is highly significant. It has been considered as alakshana of medovruddhi in Ayurveda195 and a number of respiratory disorders canresult in severe cases of Sthoulya.Atikshuda: Atikshuda was present in all the patients and a relief of 46% was observedafter the clinical study. Acharya Charaka has mentioned Atikshuda as one of the Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya122
    • DiscussionAsthadoshas of Sthoulya196 and the prevalence of the Atikshuda in all the patientsjustifies this fact. The atisanduksana of the koshtagata agni leads to early digestion ofthe ingested food and this leads to the demand of more food, which ultimately resultsin the accumulation of more fat in the body. In the present study patient showssignificant values which can be attributed to the fact that the drug having ushna, tikta,lekhana properties counteracts the obstruction of the srotas.Swedadhikya: Out of the 25 patients, 23(92%) of the patients were having the complaint ofSwedahikya and the relief percentage was 61.8% which statistically holds highsignificance. The increase in sweda pravrutti can be attributed to the fact that Sthoulyais a meda vruddhijanya vyadhi and sweda being the mala of meda dhatu, there isincrease in swedapravruti. The high incidence of Swedahikya in the patients includedin the study, clearly justifies the mention of it amongst the Asthadoshas.Atipipasa: Atipipasa was present in all the patients and there was 46% relief after thetreatment. The loss of excessive drava dhatu in the form of ati sweda pravrutti may beresponsible for atipipasa.Dourgandhaya: Dourgandhaya was present in 23(96%) of the patients and there was 77.8%relief in the problem. The excessive secretion of sweat can be considered as the chiefcause of Dourgandhaya.Atinidra: This complaint was present in 14(56%0 of the patients and the reliefpercentage observed after the treatment was 46.3%. The involvement of Kapha dosha Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya123
    • Discussionin the pathogenesis of Sthoulya, which in turn, also vitiates the Tamas guna(manasikadosha) leads to atinidra like symptoms.Kruchvyavyata: Kruchvyavyata was present in 24% of the patients and the relief percentagewas 16.7%, which is statistically less significant. Obesity causes decrease in bloodflow to the penis and this result in Erectile Dysfunction.Dourbalya: Dourbalya was present in 24(96%) of the patients and there was 69.4% relief.The vitiation of Medadhatwagni, can be considered as the causative factor for thiscomplaint as the formation of subsequent dhatus depend on it.Weight: The maximum number of patients was in the weight range of 81-85. The meandifference in the weight after treatment was 1.86 which is highly significant. Weightgain is the main clinical manifestation of Obesity. The reduction in body weight,hence, holds great significance.BMI: The maximum number of patients was in the BMI range of 30.1-32 and theoverall mean difference in BMI after the treatment was 0.68, which statistically ishighly significant. BMI has been considered as the most precise parameter to measurebody fat. Obesity has been classified on the basis of BMI into different categoriessuch as class-I, class-II, and morbid obesity.Chest circumference: The overall mean difference in the chest circumference was 2.26, which ishighly significant. Stana lambanam has been considered as one of the lakshanas ofMedovrudhi197 and hence the reduction in it holds high significance. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya124
    • DiscussionAbdomen circumference: The mean reduction in the abdominal circumference of the patients was 2.52which is highly significant. Udara lambanam has been considered as one of thelakshanas of Medovruuddhi198 and even modern science has considered android typeof obesity, in which there is fat distribution mainly around the abdomen199.Hip circumference: The mean reduction in the hip circumference of the patients was 2.3 which isstatistically highly significant. Like stana and udara lambanam, sphika lambanam hasalso been considered as a lakshana of meda dhatu vruddhi200 and even modern sciencehas considered gynoid type of obesity, in which there is fat distribution mainly aroundthe hip and thigh region. These regions are the most probable sites of fat accumulationand hence the reduction in their respective circumferences holds high significance.Hip-waist ratio: The mean difference in the hip-waist ratio was .019 which is statisticallyhighly significant. Hip-waist ratio holds high significance in the diagnosis ofabdominal obesity.Height-weight ratio: The mean difference in the height weight ratio is .092, which also isstatistically highly significant. The difference in height-weight ratio is clearlysuggestive of the reduction in weight after treatment.Serum Lipid Profile:Table No. Showing the incidence of Serum Cholesterol levelsType No. of patients BT ATNormal lipidaemic 21 25 Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya125
    • DiscussionHyper lipidaemic 4 0Table No. Showing the incidence of Serum Triglycerides levelsType No. of patients BT ATNormal lipidaemic 9 19Hyper lipidaemic 16 6Table No. Showing the incidence of Serum HDL levelsType No. of patients BT ATNormal lipidaemic 25 25Table No. Showing the incidence of Serum LDL levelsType No. of patients BT ATNormal lipidaemic 25 25Table No. Showing the incidence of Serum VLDL levelsType No. of patients BT ATNormal lipidaemic 8 19Hyper lipidaemic 17 6 Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya126
    • Discussion Among the serum lipid profile, the serum triglyceride level shows the meandifference of 18.7; serum cholesterol level shows the men difference of 16.04, HDLlevel shows the mean difference of 0.2, the mean difference in the LDL level was11.95and the mean difference in the VLDL level was3.65. Statistically, all have highsignificance. The three main factors in the pathogenesis of obesity are excessive lipiddeposition, diminished lipid mobilization and diminished lipid utilization201. Due tothese factors there is rise in the serum lipid profile in the obese persons. Hence, serumlipid profile is an effective tool, especially in determining the complicationsassociated with obesity. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya127
    • ConclusionConclusion: Shaamana chikitsa has been considered as one of the two types of Chikitsa described in Ayurveda, viz., Shodhana and Shamana. Treatment modality like shamana therapy with Mushkakadi yoga shows good efficacy in relieving both subjective and objective parameters.This can be attributed to fact that most of the drugs of this yoga are mainly Ushna viryatamaka with Katu vipaka and predominantly Ushna and Tikta ginas and possessing lekhana,karshana and bhedana properties. By virtue of thewse properties, this yoga is Kaphashamaka as well as Medoghna. Ayurveda has mentioned mainly the subjective parameters of the Sthoulya but these along with the objective parameters mentioned in the modern science helps not only in the diagnosis of the disease but also in the result evaluation of a particular therapy. There is a misconception related to the relation between obesity and hyperlipideamia. An obese person is generally considered to be having high lipid levels but the study rejects this. The results show that an obese person may or may not have hyperlipideamia Both Sthoulya and Obesity can, undoubtedly be compared on the basis of the etiological factors, pathogenesis (samprapti), signs and symptoms All the Objective parameters, viz. BMI, weight, body circumference, hip- waist ratio, height –weight ratio shows considerable changes, which statistically also are highly significant. Amongst the bio-chemical values, besides the HDL, all other values showed reasonable decrease in their respective values. This proves the action of the drug on the lipid profile Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya128
    • Conclusion In modern medicine, several drugs like Amphetamines, Sibutramine and Orlistat are recommended for the management of Obesity along with some surgical procedures like baratric surgery and liposuction. But all these, have their own side effects. Hence an Ayurvedic approach to this problem must be taken into consideration. By reviewing the literary research, it becomes obvious that along with the proper chikitsa therapy (shamana/shodhana), Pathya-apathya plays a vital role in the management of Sthoulya. The diet regimen, as mentioned in Ayurveda should also be strictly followed in the management of Sthoulya, as the improper dietic habits such as Adhyashana and Vishamashana are the etiological factors of Sthoulya.Recommendations for the further study: Since the sample size taken for this clinical study was small, it was hard to conclude about the incidence of the disease with respect to some demographical data. Hence, it is recommendable that, in future, the study should be performed on a larger sample. Shamana chikitsa is basically concerned with the shamana/depression of the vitiated doshas within the body. Though effective, but if used in association with some Bahirparimarjana measures like Udavartana the results can be much better. Sodhana therapy is a special tool of Ayurveda, which if handed properly, can prove to be a masterpiece in the management of Sthoulya A number of lekhana bastis had been mentioned in classical Ayurvedic texts. A thorough research on the mode of action of these bastis and their effect on the bio- chemical is necessary. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya129
    • ConclusionThe research conducted by the director of Scripps institute of research inIajolia, California, Dr. Kim Jianda for discovering a vaccine for obesity thatagainst the hunger hormone called Ghrelin and that conducted by NikhilDhurandhar and his team that shows the role of Ad-36 virus in thepathogenesis of obesity, have brought about a new revolution in the field ofmodern medical science. Similar research works are needed in Ayurveda tocounter this disease. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya130
    • SummarySummary: The present study entitled ‘Evaluation of the Mushkakadi Yoga in themanagement of Sthoulya (obesity)” consists of 7 parts. 1. Introduction 2. Objectives 3. Review of literature 4. Methodology 5. Results 6. Discussion 7. ConclusionIntroduction: This part consists of general description of Ayurveda, its origin, meaning,objectives and utility of the study in modern era. It gives a brief description of thedisease sthoulya, the trial drug Mushkakadi yoga, the study design and themethodology adopted for this study.Objectives of the study: This part consists of the purpose of the study and the objectives of the study.Review of the literature: This portion consists of two parts, i.e., disease review and drug review.Disease review consists of historical review, vyutpatti and nirukti of sthoulya.Besides, the nidana, poorvaroopa, samprapti, roopa etc of sthoulya as described inclassical Ayurvedic texts has also been elaborated. The disease Obesity along with itsetiology, pathogenesis, types, signs and symptoms, treatment and complications hasalso been described .In the drug review, the drugs used in the formulation of Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya131
    • SummaryMushkakadi yoga has been discussed. The action of every individual drug on thedoshas and their properties has been elaborated.Methodology: This part deals with the preparation of the trial drug, its posology and thestudy design, subjective parameters, objective parameters with their grading anddiagnostic criteria and criteria for the assessment of results.Observations and Results: This part consists of the demographic data of the patients on whom the trialwas done, response to treatment, comparison of the subjective and objectiveparameters before and after treatment and the overall response to the treatment.Results are given in form of tables along with demographical charts. Theimprovements in selected parameters are statistically analyzed and presented in theform of tables and graphs.Discussion: This part consists of four sections. First section entitled – Discussion onReview of literature deals with the disease review as well as the drug review. Thedisease review deals with the nidana(etiology), purvarupa (premonitory symptoms),rupa (clinical features), samprapti (pathogenesis) , upadrava (complications), chikitsa(treatment) and pathya-apathya of the disease Sthoulya according to classicalAyurvedic texts and modern medicine. The dug review deals with the reference of theYoga in classical Ayurvedic text and its composition The second section entitled-Discussion on the materials and methods deals with the materials taken for the clinicalstudy, i.e., the collection of data, the type of therapy, the medicine and its posology,the study duration etc .The methodology part deals with the assessment criteria of theresults based on grading of the individual parameters (subjective and objective). The Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya132
    • Summarythird portion –Discussion on clinical study and the fourth section-Discussion on theresults deals with the observational study about the incidence of the disease accordingto the demographic factors and the results experienced. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya133
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    • Bibliography158. Agnivesha, Charaka Samhita, Sutrasthana, Chapter No.23, Sloka No.6-9, Editor Gangasahaya Pandeya, 5th Edition, Varanasi, Chaukhambha Sanskrit Sansthana, 1997, Pg. No. 296.159. Sushruta, Shushruta Samhita, Chukitsasthana Chapter No, 32, Sloka No.15, Kaviraj Ambika Datta Shastri Editor. 14th Edition. Varanasi. Chaukhambha Sanskrit Samsthana 2003, Pg. No. 140.160. Ibid, Chapter No.33, Sloka No.18, Pg. No. 143.161. Vriddha Jivaka, Kashyapa Samhita, Siddhasthana, Chapter No. 2, 3rd Edition, Varanasi, Chaukhambha Sanskrit Sansthana, Pg.No.150.162. Vagabhata, Asthanga Hrudyam, Sutrasthana, Chapter No.14, Sloka No.14, Editor Indradev Tripathi, 1st Edition, Varanasi, Krishna Das Academy, 1994, Pg. No. 149.163. Sushruta, Shushruta Samhita, Chukitsasthana Chapter No, 38, Sloka No.82, Kaviraj Ambika Datta Shastri Editor. 14th Edition. Varanasi. Chaukhambha Sanskrit Samsthana 2003, Pg. No. 174.164. Sharangdhara,Sharangdhara Samhita, Prathamkhanda, Chapter No.4, Sloka No. 10, 4th Edition, Varanasi, Chaukhambha Orientalia, 2001, Pg. No.18.165. Vriddha Jivaka, Kashyapa Samhita, Chikitsasthana Medasvi Dhatri Chikitsa, 3rd Edition, Varanasi, Chaukhambha Sanskrit Sansthana , Pg.No.140.166. Ibid, Siddhasthana, Chapter No.2, Pg. No.150.167. Sushruta, Shushruta Samhita, Chukitsasthana Chapter No, 37, Sloka No.33- 35, Kaviraj Ambika Datta Shastri Editor. 14th Edition. Varanasi. Chaukhambha Sanskrit Samsthana 2003, Pg. No. 161.168. Agnivesha, Charaka Samhita, Sutrasthana, Chapter No.21, Sloka No.20-21, Editor Gangasahaya Pandeya, 5th Edition, Varanasi, Chaukhambha Sanskrit Sansthana, 1997, Pg. No. 282.169. Agnivesha, Charaka Samhita, Sutrasthana, Chapter No.21, Sloka No.17, Editor Dr. Brahmanand Tripathi, 11th Edition, Varanasi, Chaukhambha Subharati Prakashan, 2003, Pg. No.402.170. Agnivesha, Charaka Samhita, Sutrasthana, Chapter No.21, Sloka No.22-24, Editor Dr. Brahmanand Tripathi, 11th Edition, Varanasi, Chaukhambha Subharati Prakashan, 2003, Pg. No.404. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya145
    • Bibliography171. Harrison’s Principle of Internal Medicine, Vol-1, Part-5, Chapter No.75, Editor Anthony. S. Fauci and Joseph. B. Martin, 14th Edition, International edition, 1998, Pg. No. 460.172. http://health.nytimes.com/health/guides/specialtopic/weight- management/overview.html173. Harrison’s Principle of Internal Medicine, Vol-1, Part-5, Chapter No.75, Editor Anthony. S. Fauci and Joseph. B. Martin, 14th Edition, International edition, 1998, Pg. No. 460.174. http://health.nytimes.com/health/guides/specialtopic/weight- management/overview.html175. Golwalla, Medicine for Students, Chapter No 5, 18th Edition, Mumbai, Dr.A.F.Golwalla Empress Court Church Gate, 1999, Pg. No. 340.176. Harrison’s Principle of Internal Medicine, Vol-1, Part-5, Chapter No.75, Editor Anthony. S. Fauci and Joseph. B. Martin, 14th Edition, International edition, 1998, Pg. No. 460.177. Davidson’s Principle and Practice of Medicine, Chapter No.10, Editor Christopher Haslet and Edwin .R. Chilvers. 19th Edition, Churchill Livingtone, 2002, Pg. No.304.178. Towards a possible Vaccine against Obesity; Hindu, 2nd August 2006, New Delhi, Pg. No.20.179. Davidson’s Principle and Practice of Medicine, Chapter No.10, Editor Christopher Haslet and Edwin .R. Chilvers. 19th Edition, Churchill Livingtone, 2002, Pg. No.305.180. KD Tripahi, Essentials of Medicaj Pharmacology, Chapter No.8, 4th Edition, New Delhi, Jaypee Brother’s Medical Publishers; 1998.pg.no.127.181. API, Text Book of Medicine, Editor Gurumuk.S.Sainani, Chapter No.11, 6th Edition, Mumbai, Association of physicians of India, 1999, Section 4, Pg. No.210.182. Rober Fear, Obesity Surgery Risks gets bigger; First Bariatric Surgery; many methods; Deccan Chronicle July 27th, 2006, Health plus column.183. Agnivesha, Charaka Samhita, Sutrasthana, Chapter No.21, Sloka No.25-27, Editor Gangasahaya Pandeya, 5th Edition, Varanasi, Chaukhambha Sanskrit Sansthana, 1997, Pg. No. 282. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya146
    • Bibliography184. Sushruta, Shushruta Samhita, Sutrasthana, Chapter No, 15, Sloka No.38, Kaviraj Ambika Datta Shastri Editor. 14th Edition. Varanasi. Chaukhambha Sanskrit Samsthana 2003, Pg. No.62.185. Vagabhata, Asthanga Hrudyam, Sutrasthana, Chapter No.14, Sloka No.21, Editor Indradev Tripathi, 1st Edition, Varanasi, Krishna Das Academy, 1994, Pg. No. 150.186. Yogaratnakar, Yogratnakar, Medoroga Nidana Chikitsa Adhikara, Editor Brahma Shankar Shastri, 2nd Edition, Varanasi,Chaukhambha Sanskrit Series, Pg. No.102.187. Bhavamishra, Bhavaprakash, Madhyamakhanda, Chapter No.39, Sloka No. 66, 15th Edition, Varanasi, Chaukhambha Sanskrit Sansthana, 1998, Pg. No.529188. Sushruta, Shushruta Samhita, Sutrasthana, Chapter No, 38, Sloka No.20-21, Kaviraj Ambika Datta Shastri Editor. 14th Edition. Varanasi. Chaukhambha Sanskrit Samsthana 2003.189. Ibid.190. Prof. P.V. Sharma, Dravya Guna Vijyana, Vol-II, Varanasi, Chaukhambha Bharati Academy, 14th Edition, 1993.191. Prof. P.V. Sharma, Dravyaguna Vijyana, 14th Edition, Varanasi, Chaukhambha Bharati Academy, 1993, Vol II, b) Pg. No.506-509, c) Pg. No.674-676, d) Pg. No. 359-362, e) Pg. No. 376-379, f) Pg. No. 463-466, g) Pg. No. 806-808, h) Pg. No. 430-433, i) Pg. No. 753-758, j) Pg. No. Pg. No.239-241, k) Pg. No.758-760.192. Agnivesha, Charaka Samhita, Sutrasthana, Chapter No.21, Sloka No.4, Editor Dr.Brahmanand Tripathi, 11th Edition, Varanasi, Chaukhambha Subharati Prakashan, 2003, Pg. No.399.193. Ibid.194. Vagabhata, Asthanga Hrudyam, Sutrasthana, Chapter No.11, Sloka No.10- 11, Editor Indradev Tripathi, 1st Edition, Varanasi, Krishna Das Academy, 1994, Pg. No.90.195. Sushruta, Sushruta Samhita Sutrasthana, Chapter 15, Sloka No.14, Dr.Sri Bhaskar Govindji Ghanekar Editor, 10th Edition, New Delhi, Motilal Banarasidas;2002, PgNo.57. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya147
    • Bibliography196. Agnivesha, Charaka Samhita, Sutrasthana, Chapter No.21, Sloka No.4, Editor Dr.Brahmanand Tripathi, 11th Edition, Varanasi, Chaukhambha Subharati Prakashan, 2003, Pg. No.399197. Vagabhata, Asthanga Hrudyam, Sutrasthana, Chapter No.11, Sloka No.10- 11, Editor Indradev Tripathi, 1st Edition, Varanasi, Krishna Das Academy, 1994, Pg. No.90.198. Vagabhata, Asthanga Hrudyam, Sutrasthana, Chapter No.11, Sloka No.10- 11, Editor Indradev Tripathi, 1st Edition, Varanasi, Krishna Das Academy, 1994, Pg. No.90.199. Davidson’s Principle and Practice of Medicine, Chapter No.7, Editor Christopher Haslet and Edwin .R. Chilvers. 18th Edition, Churchill Livingtone, 1999, Pg. No.526.200. Vagabhata, Asthanga Hrudyam, Sutrasthana, Chapter No.11, Sloka No.10- 11, Editor Indradev Tripathi, 1st Edition, Varanasi, Krishna Das Academy, 1994, Pg. No.90.201. K.Sembulingham, Essentials of Medical Physiology, Chapter No.67, 3rd Edition, New Delhi, Jaypee Brothers Medical Publishers (P) Ltd, 2005, Pg No. 316-317 & 350. Evaluation of Efficacy of Mushkakadi Yoga in Sthoulya148
    • Annexure AnnexureDEPARTMENT OF POST GRADUDUATE STUDIES IN KAYACHIKITSA D.G.M.AYURVEDIC MEDICAL COLLEGE, HOSPITAL, POST GRADUATE STUDIES AND RESEARCH CENTRE.GADAG SPECIAL CASE SHEET FOR STHOULYACandidate: Guide:Dr. Shekhar Sharma Dr. R.V.Shettar M.D. Scholar M.D.(Ayu)1. Name of the patient Sl.No.2. Father’s/Husband’s Name O.P.D. No.3. Age4. Sex Male Female5. Religion Hindu Muslim Christian Others6. Marital Status Married Unmarried7. Habitat Urban Suburban Rural8. Address9. Date of initiation of treatment10. Date of completion of treatment11. Result Good Moderate Mild No12. Consent I here by agree that, I have been fully educated with thedisease and treatment. Hereby satisfied whole heartily, accept the medical trial overme.Investigator’s Signature Patient’s Signature 1
    • AnnexureA) PRADHANA VEDANA Duration Before treatment After treatment Kshudatimatra Pipasatiyogasha Swedadikyata Dourgandhya Kruchvyavata Gatrasada Angagaurava Nidradikyata KshudraswasaB) ANUBANDHI VEDANA Duration Before treatment After treatment Aruchi Kriya asamartata Vyayama asamartata Shareera gauravata Talu shosha Alasya DourbalyaC) Poorvavydhi Vrittanta:D) Chikitsa vrittanta:E) Kula vrittanta: Paternal Maternal 2
    • AnnexureF) Vayaktika vrittanta:a) Ahara:Ahara Vegetarian MixedPradhana Rasa; Madhura Amla Lavana Katu Tikta KashayaDietary habits:Bakery Items: Frequently Occasionally NeverAgni: Manda Teekshna Vishama SamaKoshta: Mrudu Madhyama Kroorab) Vihara:Occupation: Sedentary Active Labour OthrersNidra: Sukha Alpa Ati Vishama DiwaswapnaVyayama: No Occasionally EverydayArtava Vrittanta: Menarche Menopause Menstrual Cycle Days Samanya Alpa Adhika 3
    • AnnexureVyasana; No Occasionally Everyday Alcohol Tobacco Smoking Tea/CoffeeG) EXAMINATION OF PATIENT(1) Asta sthana Pareeksha: Nadi Mala pravriti Mootra Frequency Pravriti Day Night Jiwha Shabda Sparsha Druk Akruti(2) Vital Examination; o Temperature F Pulse bpm Blood Pressure mm of Hg Respiration Rate /min 4
    • Annexure(3) Dashaveedha Pareeksha:Prakritti Shareera V P K VP PK KV Manasika S R SR ST TRVikrittiSamhanana Pravara Madhyama AvaraSaraPramanaSatmyaSatvaAhara Shakti Abhyavarahana Shakti Pravara Madhyama Avara Jarana Shakti Pravara Madhyama AvaraVyayamaShaktiVaya Bala Yauvam Madhya Vruddha(4) Strota Pareeksha: Strotas Observed Lakshanas Annavaha strotas Rasavaha strotas Mamsaveha strotas Medaveha strotas Udakaveha strotas Swedaveha strotas(5) General Examination:(a) Samanya Pareeksha:1) Ura Pareeksha 5
    • Annexure i. Inspection ii. Palpation iii. Percussion iv. Auscultation2) Udara Pareeksha i. Inspection ii. Palpation iii. Percussion iv. Auscultation(b) Vishesha Pareeksha: Weight kg Height Cm Chest Circumference cm Hip Circumference cm Abdominal Circumference cm Hip-Waist ratio Body Mass Index kg/m2 Skin fold thickness mmH) Laboratory Investigations: Before Treatment After Treatment Haemoglobin% Total Blood Count Polymorph Lymphocyte Differential Eosinophils Count Basophils Monocytes ESR RBS Urine Examination Stool Examination Lipid Triglyceride Profile T-Cholesterol HDL-Cholesterol LDL-Cholesterol 6
    • Annexure V.L.D.L.VIKTUTTI PAREEKSHA(1) Nidana Ahara Vihara Manasika Sleshmala Avyayama Chinta Madhura Chestadwesha Shoka Sneha Arati Bhaya Adhyasana Diwswapna Krodha Guru Shayya, Harshita Asanasukha Atimatrahara(2) Poorva Roopa(3)Roopa P/A Duration Kshudatimatra Pipasa atiyogasha Sweda adikyata Dourgandhya Kruchvyavta Gatrasada Angagaurava Nidra adikyata KshudraswasaCHIKITSA * Mushkakadi Yoga From to Follow- up 7
    • Annexure From to * Anupana Assessment SheetClinical Parameters During treatment Schedule Follow up In days F1 F2 st th th th th tha) Subjective 1 15 30 45 60 75 90th1. Sthana Chalatava2. Udara Chalatwa3. Sphika Chalatwa4. Kshudra Swasa5. Akshuda6. Atipipasa7. Swedadhikaya8. Dourgandhya9. Atinidra10. Kruchvyayvata11. Dourbalyab) Objective1. Weight2. BMI3. Chest Circumference4. Hipcircumference5. Abdamen circumference6. Hip wast ratio7. Height weight ratioc) Lab Investigation BT ATSerum cholesterolSerum triglyceridesHigh density lipoproteinLow density lipoproteinV.L.D.L.Investigators NoteSignature of Guide Signature of Scholar (Dr. R. V. Shettar) (Dr. Shekhar Sharma) 8
    • AnnexureMethod of Assessment of treatment :Subjective and objective parameters are taken for the assessment of results. Separategrading has been given for subjective parameters that include the following : Chala sphika stana udara Grade Absence of chalatva 0 Little visible movement (in these areas) after fast movement 1 Little visible movement (in the areas) even after moderate movement 2 Movement (in the areas) after mild movement 3 Movement (in the areas) even after changing posture 4 Kruchyayvata No problem in sexual intercourse 0 Occasionally problem of erectile dysfunction 1 Frequently having the problem of erectile dysfunction 2 No desire of sexual activity 3 Can not perform sexual activity 4 Dourbalya: Can do routine exercise 0 Can do moderate exercise without difficulty 1 Can do only mild exercise 2 Can do mild exercise with very difficulty 3 Cannot do even mild exercise 4 Swedadikyata: Sweating after heavy work and fast movement Or in hot season 0 Profuse sweating after moderate work and movement 1 Sweating after little work and movement 2 Profuse sweating after little work and movement 3 Profuse sweating without any exercise 4 9
    • AnnexureDaurgandhyata:Absence of bad smell 0Occasional bad smell from the body, which removed After bathing 1Persistent bad smell limited to close areas difficulty to Suppress with 2deodorantsPersistent bad smell felt from long distance and is not Suppressed by 3deodorantsPersistent bad smell felt from long distance even Intolerable to the patient 4himselfKshudraswasaNo Dyspnoea 0Dyspnoea in resting condition 1Dyspnoea after little work but relieved later and beyond tolerances 2Dyspnoea after moderate work but relieved later and beyond tolerances 3Dyspnoea after heavy work but relieved soon and up to tolerance 4Atinidra:No day sleep can get up early, night sleep<6 hrs. 0Can avoid day sleep easily bit drowsy, night sleep<7-8 hrs 1Cannot avoid day sleep drowsy, day sleep 1-2 hrs and night sleep 8-9 hrs 2Always drowsy, sleepy, day sleep 3-4 hrs and night sleep 9-10 hrs 3Sleep while sitting itself, day sleep 5-6 hrs and night sleep>10 hrs 4Atikshudha:Atikshudha was decided on the basis of ruchi, abhyavaharana shakti and jaranashakti.A) Abhyavaharana Shakti:Person taking food in less quantity once in a day 0Person taking food in less quantity twice in a day 1 10
    • AnnexurePerson taking food in moderate quantity twice in a day 2Person taking food in normal quantity twice a day 3Taking food in excessive quantity twice or thrice 4B) Jarana Shakti:According to presence of jirna aahara lakshana (M.N.6/24), utsahaha, laghuta, udgarshuddhi, kshudha, trushna pravrutti yathochita malotsarga.Presence of one symptom after 6 hours 0Presence of two symptoms after 6 hours 1Presence of three symptoms after 5 hours 2Presence of four symptoms after 5 hours 3Presence of all symptoms after 4 hours 4C) Ruchi:Totally unwilling for meal 0Unwilling for food, but could take the meal 1Willing towards only most liking food, and not to other 2Willing towards some specific aahara or rasa visesha 3Equal willing towards all the bhojya padartha 4Ati Pipasa:Normal thirst 0Upto1 liter excess intake of water 11 to 2 liters excess intake of water 22 to 3 liters excess intake of water 3More than 3 liters excess intake of water 4 OBJECTIVE CRITERIA:Weight:Grade -0 Above 3 kgGrade –1 Up to 3 kg 11
    • Annexure Grade –2 Up to 2 kg Grade –3 Up to 1 kg Grade –4 no change (Basic) B.M.I.: Grade –0 Above 1.20 Grade –1 .90 - 1.19 Grade –2 .60 - .89 Grade –3 .30 - .59 Grade –4 .00 - .29 In general body circumference for chest, abdomen, waist, hip, waist and hip ratio: Grade –0 Above 1.60 Grade –1 1.20 – 1.59 Grade –2 .80 – 1.19 Grade –3 .40 - .79 Grade –4 .00 – 39Overall assessment:• Good respond - > 70% in both subjective and objective parameters• Moderate respond – 50-70% in both subjective and objective parameters• Mild respond -30-50% in both subjective and objective parameters• No respond - < 30% in both subjective and objective parameters. 12
    • Showing data related to objective parameters before and after treatmentSl. OP Ht.i Wt. in kg. CIRCUMFERENCE BMI (kg/m2) H:W HT./WT. ResultsNo D meter Chest Hip Abdomen NO s B AT AF BT AT AF BT AT AF BT AT AF BT AT AF BT AT AF BT AT AF T1 4272 1.65 86 83 83 102 100 101 105 102 102 107 104 103.5 31.6 30.48 30.48 0.98 0.98 0.985 1.92 1.98 1.98 MoR2 4294 1.70 90 88 89 95 92.5 93 107 106 106 95 93.5 94 31 30.44 30.79 1.12 1.13 1.12 1.88 1.93 1.91 MiR3 4469 1.52 88 87 87 88 85 85.5 108 104 105 110 107 107 38.2 37.65 37.65 0.98 0.97 0.981 1.72 1.74 1.74 MoR4 4486 1.55 76 76 76 92 91.5 92 102 101.5 101.5 97 96 96.5 31.7 31.7 31.7 1.05 1.057 1.051 2.03 2.03 2.03 MoR5 4657 1.52 85 82 82 106 103 104 140 138 137 104 101 100 36.7 35.49 35.49 1.34 1.366 1.37 1.79 1.85 1.85 MoR6 4781 1.44 74 72.5 72 102 100 100 112 109 109 102 100.5 100 35.6 34.96 34.72 1.09 1.08 1.09 1.94 1.986 2.0 MoR7 5002 1.50 89 86.5 87 115 111 111 123 122 122 110 107 107.5 39.5 38.44 38.66 1.11 1.14 1.13 1.68 1.734 1.724 GR8 5003 1.54 85 84 84 87 84.5 85 138 136.5 136 81 80 80 35.8 35.41 35.41 1.70 1.706 1.7 1.81 1.83 1..83 MoR9 5004 1.53 90 88.5 88 110 108.5 108 121 119 119 110 108.5 108 37.9 37.80 37.59 1.1 1.09 1.10 1.7 1.728 1.738 MiR10 5005 1.55 85 82 82 138 135. 135.5 111 108 108 101 99 98 35.3 34.13 34.13 1.09 1.09 1.10 1.82 1.89 1.89 MiR11 5006 1.48 80 80 80 90 90 90 104 103 103 102 100.5 101 36.5 36.5 36.5 1.01 1.024 1.019 1.85 1.85 1.85 MiR12 5836 1.56 84 82.5 83 88 86 86 140 137 137 84 83 83.5 34.5 33.90 34.10 1.66 1.65 1.64 1.85 1.89 1.879 GR13 6332 1.60 84 81.5 81 94 91.5 91 110 108 108 108 105 104 32.8 31.83 31.64 1.01 1.028 1.038 1.90 1.963 1.975 MoR14 5838 1.65 85 84 84 100 99 99 103 101 101 107 104 104.5 31.2 30.85 30.85 0.96 0.97 0.966 1.94 1.96 1.96 MoR15 5845 1.48 80 79.5 79.5 84 84 84 100 100 100 106 105 105 36.5 36.29 36.29 0.94 0.95 0.95 1.85 1.861 1.861 GR16 6434 1.48 78 77 77 82 80 80.5 122 119.5 119 83 80 80 35.6 35.15 35.15 1.46 1.49 1.48 1.89 1.92 1.92 MiR17 120 1.60 80 77 76.5 86 83.5 83 98 95 95 104 101 101 31.25 30.07 29.88 0.94 0.94 0.94 2.0 2.07 2.09 MoR18 427 1.60 83 80.5 80 104 101 100 106 103.5 104 109 106 106 32.4 31.44 31.25 0.97 0.97 0.98 1.92 1.98 2.0 MoR19 428 1.58 82 80 80 102 99 99 105 102 102.5 106 103 102 32.8 32.04 32.04 0.99 0.99 1.004 1.92 1.975 1.975 MoR20 430 1.52 84 81 81 88 86 86 104 100 101 110 106 106 36.3 35.05 35.05 0.94 0.94 0.95 1.80 1.876 1.876 GR21 429 1.55 85 82.5 83 90 88 88 106 103 103 112 108.5 108 35.3 34.33 34.54 0.94 0.94 0.95 1.82 1.878 1.867 MoR22 470 1.64 84 83 83.5 90 86.5 86.5 102 99 99 108 104 104 31.1 30.85 31.04 0.94 0.95 0.95 1.95 1.97 1.964 MoR23 314 1.48 82 80 80 86 83 83 98 96.5 96 104 101.5 101 37.4 36.52 36.52 0.94 0.95 0.95 1.80 1.85 1.85 MoR24 608 1.56 76 73.5 74 88 84 84.5 102 99.5 100 108 105 105 31.6 30.20 30.40 0.94 0.947 0.95 2.1 2.12 2.108 MoR25 514 1.66 84 81 81 88 86 87 102 99 99 106 102 101.5 30.4 29.45 29.4 0.96 0.97 0.975 1.98 2.05 2.05 MiR
    • Showing Demographical data related to evaluation of Mushakakadi Yoga in SthoulyaSlno OPDNO Age Sex Religion M.Status Occ.Status Diet Agni Koshtha Pradhana Prakriti Family Results Rasa history1 4272 - - - + + - + - - + - + - - - - + - - + - - + Katu KV P MoR2 4294 + - - - + - + - - - + - + - - - + - + - - - + Madhura PK A MiR3 4469 - + - - - + + - - + - - + - - + - - - + + - - Madhura PK A MoR4 4486 - - - + - + + - - + - - + - - + - - + - + - - Madhuta KV A MoR5 4657 - + - - - + + - - + - - + - - - + - - + - - + Madhuta KV A MoR6 4781 - + - - - + + - - + - - + - - + - - - + + - - Madhura PK P MoR7 5002 - - + - - + + - - + - + - - - - + - + - + - - Amla KV P GR8 5003 - - + - - + + - - + - - + - - - + - + - + - - Katu PK A MoR9 5004 - - + - - + + - - + - - + - - - + - - + + - - Katu PK P MiR10 5005 - + - - - + + - - + - + - - - + - - - + + - - Katui VP P MiR11 5006 - + - - - + + - - + - + - - - + - - + - + - - Madhura KV A MiR12 5836 - - - + + - - + - + - + - - - - + - - + + - - Katu VP P GR13 6332 + - - - + - - + - - + - + - - - + - + - + - - Amla PK A MoR14 5838 + - - - + - - + - - + - + - - - + - + - + - - Katu PK P MoR15 5845 + - - - - + - - + - + - + - - - + - - + - - + Amla PK P GR16 6434 - + - - - + - + - + - - + - - - + - + - + - - Amla PK A MiR17 120 + - - - - + - - + - + + - - - - + - - + - - + Katu PK A MoR18 427 + - - - + - - + - - + + - - - - + - + - + - - Madhura KV A MoR19 428 + - - - + - - + - - + + - - - - + - + - - - + Madhura VP P MoR20 430 + - - - + - - - + + - + - - - - + - + - - - - Madhura KV A GR21 429 - + - - + - - - + + - + - - - - + - + - + - - Madhura KV A MoR22 470 - - + - + - + - - + - + - - - + - - - + + - - Madhura VP A MoR23 314 - + - - + - + - - + - + - - - - + - + - - - + Amla PK A MoR24 608 + - - - - + + - - - + - + - - - + - - + - - + Katu KV P MoR25 514 - - + - + - + - - + - + - - + - - - + - - + Madhura VP A MiR
    • Showing data related to subjective parameters before and after treatmentSl no OPD Sthana Udara Sphika Kshudra Atikshu Atipipas Swedad Dourgan Atinidra Kruchvy Dourbal Results chalatva chalatva chalatva swasa da a hikya dhya ayvata ya BT AT BT AT BT AT BT AT BT AT BT AT BT AT BT AT BT AT BT AT BT AT1 4272 3 2 2 1 2 1 1 0 3 2 1 0 2 1 - - 2 1 - - 1 0 MoR2 4294 - - 3 2 2 2 2 1 3 2 2 1 1 0 1 1 3 2 - - 2 1 MiR3 4469 2 1 2 1 2 1 1 0 3 2 2 1 2 1 2 1 - - 1 1 1 0 MoR4 4486 2 1 3 2 2 1 - - 2 1 2 1 - - - - 1 0 - - 1 0 MoR5 4657 1 0 2 1 2 2 1 0 3 2 2 1 2 1 1 0 - - - - 2 1 MoR6 4781 2 1 2 1 2 2 - - 3 2 2 1 2 0 1 0 2 1 - - 2 1 MoR7 5002 - - 1 0 1 0 1 0 1 0 1 1 - - 1 0 2 1 - - - - GR8 5003 3 1 2 0 2 1 3 1 2 1 2 1 2 1 2 1 - - - - 2 1 MoR9 5004 3 2 3 1 4 3 4 2 3 2 2 1 3 2 2 1 3 2 1 1 3 2 MiR10 5005 2 1 2 1 2 1 2 0 2 1 1 1 2 2 2 1 - - 1 1 2 0 MiR11 5006 3 2 3 2 4 3 2 1 2 1 2 1 3 1 3 1 3 2 - - 2 1 MiR12 5836 - - 3 1 2 1 1 0 2 1 2 1 2 1 1 0 - - - - 1 0 GR13 6332 1 0 2 1 2 2 2 1 3 2 2 1 2 1 1 0 2 1 - - 1 0 MoR14 5838 2 1 2 1 2 1 - - 3 2 2 1 2 1 1 0 3 1 - - 2 0 MoR15 5845 1 1 3 2 1 0 1 0 3 1 2 1 1 0 1 0 - - - - 1 0 GR16 6434 2 2 3 2 4 3 2 1 3 1 2 1 2 0 2 1 - - - - 3 2 MiR17 120 - - 2 1 2 2 - - 2 1 1 1 1 0 1 0 2 1 - - 2 1 MoR18 427 - - 3 2 2 1 1 01 3 1 3 2 1 0 2 1 2 1 - - 3 2 MoR19 428 1 0 2 2 - - 2 1 3 1 2 1 2 1 2 0 3 1 1 1 2 0 MoR20 430 - - 2 1 - - 1 0 3 1 2 0 1 0 1 0 3 1 - - 2 1 GR21 429 3 2 4 3 3 2 2 0 3 2 2 1 3 2 2 0 2 1 - 1 0 MoR22 470 2 2 4 2 3 1 1 0 3 1 1 1 2 1 2 0 - - 1 0 2 1 MoR23 314 2 1 4 3 2 2 2 0 3 2 3 1 2 1 1 0 - - - - 2 1 MoR24 608 3 1 4 2 3 1 - - 3 2 3 1 2 0 2 0 - - - - 2 1 MoR25 514 2 2 3 2 2 2 - - 3 1 3 2 2 1 1 0 - - 1 1 3 1 MiR