Sthoulya kc004 gdg

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TRYUSHANADYA LOHAM IN STHOULYA (OBESITY) WITH SPECIAL REFERENCE TO
HYPERLIPIDAEMIA By Shakuntala C. Garwad, Post Graduate Studies & Research Center, D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG

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Sthoulya kc004 gdg

  1. 1. EVALUATION OF THE EFFICACY OF TRYUSHANADYA LOHAM IN STHOULYA(OBESITY) WITH SPECIAL REFERENCE TO HYPERLIPIDAEMIA By Shakuntala C. GarwadAs partial fulfillment of the Post-graduation degree Ayurveda Vachaspati M.D. (Kayachikitsa)Under Rajiv Gandhi University of Health sciences Bangalore, Karnataka. Guide Dr. Vangipuram Varadacharyulu M. D. (Ayu) Professor and Head of the department, Kayachikitsa. Post graduation studies and research. D.G.Melmalagi Ayurvedic Medical College Gadag- 582103.
  2. 2. Department of Postgraduate Studies and Research Kayachikitsa.
  3. 3. POST GRADUATION AND RESEARCH CENTER, KAYACHIKITSA. D.G.M. Ayuyrvedic Medical College, Gadag. Certificate This is to certify that the thesis entitled “Evaluationof the efficacy of Tryushanadya Loham in Sthoulya(Obesity) with special reference to Hyperlipidaemia” is arecord of research work conducted by Dr. Shakuntala C.Garwad under my close supervision and guidance. The candidate has put in sincere effort after makingan intense study coupled with theoretical and clinicalobservations. This title has not found title of degree, associateship,fellowship and similar other studies in this University. I recommend the same for being submitted forevaluation to the adjudicators. GuidePlace : Dr. Vangipuram Varadacharyulu M. D. (Ayu)Date : Professor and Head of the department Post graduation studies and research, Kayachikitsa.
  4. 4. J.S.V.V.S. SAMSTHE’S SHRI D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, POST GRADUATION AND RESEARCH CENTER, GADAG-582103. Certificate This is to certify that Dr. Shakuntala C. Garwad hasworked for her thesis on the topic entitled“Evaluation ofthe efficacy of Tryushanadya Loham in Sthoulya(Obesity) with special reference to Hyperlipidemia” She has successfully done the work under theguidance of Dr. Vangipuram Varadacharyulu M. D. (Ayu) This particular study helps in treating the diseaseSthoulya with present scientific approaches. I here with forward this thesis for the evaluation andadjudication. Dr. G.B. Patil. Principal / C. M. O.
  5. 5. Contents Page No.1. Introduction 1-32. Literary review 4-33 a) Historical review 4-6 b) Nidana 7-11 c) Samprapti 12 -15 d) Poorva roopa 16-16 e) Roopa 17-23 f) Classification 24-25 g) Sadhyasadhyata 26-26 h) Upadrava 27-29 i) Chikitsa 30-333. Modern view 34-544. Drug review 55-745. Materials and methods 75-856. Observations and results 86-1067. Master charts 107-1158. Discussion 116-1239. Conclusion 124-12410. Summary 125-12611. References and Bibliography 127-135 Case sheet Appendix
  6. 6. List of abbreviationsCha. – Charaka SamhitaSus. – Sushruta SamhitaAs. – Ashtanga SangrahaAh. – Ashtanga HridyaMa. Ni. – Madhava NidanaBh. P. – BhavaprakashaSha. Sa. – Sharangadhara SamhitaChak. – ChakrapaniGang. – GangadharaAru. – ArundattaDal. – DalhanaSa. – Shareera SthanaNi. – Nidana SthanaChi. – Chikitsa SthanaSu. – Sutra StahnaKa. – Kalpa Sthana
  7. 7. List of graphs Page No.01.Graph showing the age incidence 8602.Graph showing the sex distribution 8703.Graph showing the religion distribution 8804.Graph showing the occupation distribution 8905.Graph showing the economical status 9006.Graph showing the distribution food habit 9107.Graph showing the incidence family history 9208.Graph showing the chronicity of the disease 9309.Graph showing the distribution personal history 9410.Graph showing the adhyashana of the patients 9511.Graph showing the Vyayama of the patients 9612.Graph showing the diavaswapna of the patients 9713.Graph showing the Vyavaya of the patients 9814.Graph showing the distribution of the mental status 9915.Graph showing the pattern of sleep 10016.Graph showing the data related to results 101
  8. 8. Master charts Page No.01.Data related to demography 10702.Data related to personal history 10803.Data related to complaints 10904.Data related to associated symptoms 11005.Data related to upadrava 111-11206.Data related to weight, height, and circumference 11307.Data related to objective parameters 114-115
  9. 9. List of tables Page No.01.Table showing nidana of Sthoulya by different authors 702.Table showing laxanas of Sthoulya by different authors 1703.Table showing ideal weights for men 2104.Table showing ideal weights for women 2205.Table showing optimal BM I value 2306.Table showing of waist measurement 2307.Table showing Upadrava of Sthoulya by different authors 2708.Table showing type of physical activities 3109.Table showing percentage of composition of dietary fats 3610.Table showing cholesterol content of the different food 4511.Table showing classification of hyperlipidaemia 5112.Table showing total cholesterol pippetting scheme 7913.Table showing HDL cholesterol pippetting scheme 7914.Table showing triglycerides pippetting scheme 7915.Table showing the NCEP CAD risk factors 85
  10. 10. Acknowledgement At the onset my devotional Pranams to his Holiness Shri JagadguruAbhinava Shivananda Swamiji, Shivanada Matha, Gadag. I take this glorious opportunity to acknowledge with the deep sense ofgratitude to my guide, Dr. V. Varadacharyulu, Professor, Head of the department,Department of Postgraduate Studies and Research (Kayachikitsa), D.G.M.A.M.C.,Gadag, for his valuable guidance and close supervision during entire phase of thestudy. With profound sense of gratitude I express my sincere thanks to Dr. G. B.Patil, Principal, D. G. M. A. M. C, Gadag. For encouragement and facilities providedduring my postgraduate studies. I am very much thankful to Late. Dr. C. M. Sarangamath who is the rootcause of my entry into this noble profession. I remain ever great full to him. I wish to add my warmest thanks to my PG teaching faculty Dr. M. C. Patil,Dr. K. Siva Rama Prasad, Dr. Shashidhara Doddamani, Dr. Kuber Sankh, Dr. R. V.Shetter, Dr.Girish Danappagoudar for their valuable suggestions and timely helpwhich made me to complete this dissertation work successfully. I am very much thankful to Dr.S A Patil, Dr.G S Hiremath, Dr.C S Hiremath& Dr.S S Avvanni for their encouragement and moral support during the study. I extend my gratefulness and sincere heartfelt gratitude to my colleagues Dr.B. G. Swami, Dr. U. V. Purad, Dr. K S Paraddi, Dr. Shyju O. Dr. Shankaragoudaand Dr. Hanumantagouda, for their timely support during the course.
  11. 11. I am very much thankful to all UG staff and college librarian Shri. V. M.Mundinmani and other library staff for their timely help and co-operation during thestudy. I am very much thankful to my parents Smt / Dr.C M Garwad, my Brother &Sister who inspired me for higher study, rendered their valuable suggestions andencouragement throughout the study. I express my deepest gratitude to my husband Dr. M. C. Patil, without whosehelp and encouragement the work would have not been completed. Also mygratitudes are deserved for my beloved children Akshata, Arpita, Chinmaya and allmy family members who have inspired me to continue my PG study with theirconstant moral support. I thank Dr. R. S. Sarashetty for their valuable suggestions throughout thestudy. I wish to thank RMO, physicians and other hospital staff for their co-operation and all the patients who agreed to under go the treatment with trial drug. I wish to thank Giridhara North South Computer services Adarsha Nagar,Gadag. In spite of their busy schedule they completed the dissertation work neatlyand in time. I wish to thank all the persons who have helped me directly and indirectlywith apologies for my inability to identify them individually. Shakuntala C. Garwad
  12. 12. Efficacy of Tryushanadya loham in Sthoulya INTRODUCTION Ayurveda is a comprehensive health system in gaining incontrovertibleacceptability worldwide. It has a very special approach towards diseases, the patient andthe science of medicine itself. The entire system of treatment of Ayurveda revolves around Shadvidhopakramas,much importance has been given to these principles in alleviating diseases andmaintaining the good health. All the measures which are explained in Ayurvedic classicswill benefit the person or diseased in acquiring the perfect health. Thus a Comprehensive research and development within the frame of philosophy,cosmology and psychology through the scientific methodology is needed. To achieve thisgoal the integrated organization of various disciplines of sciences in the spirit of scientificinquiry coupled with zest for the social service to the mankind would also essential. Sthoulya is a Global problem and it is common among those who consumeexcessive Kapha kara ahara-vihara etc. We find no satisfactory remedies for Sthoulya incontemporary medical science. Obesity patients usually do not approach a doctor in its initial stage, but they doso in its later stage for the purpose of cosmetic value and many a time they won’t havepatience for long term therapy as complicated therapies like physical exercise and so on. In Samhita period like Charaka,Sushruta,Vagbhata samhita we get referencesregarding Sthoulya and also later works like Yogaratnakara,Bhavaprakasha AndBhaishajya ratnavali. Among the drugs used in the management of Obesity Amphetamine has a limitedscope because of its benefit for a short term goal and being contraindicated in coronary 1 Introduction
  13. 13. Efficacy of Tryushanadya loham in Sthoulyaheart disease, hypertension etc. Secondly Fenfluramine has associated adverse effects likenausea, diarrhoea, lethargy, breathlessness etc. Further an abrupt withdrawal gives rise todepression. The discovery of chemical tests for Cholesterol in the last century & finding thissubstance in atheromatous lesions, suggests a causative atherogenic role for this sterol. Inaddition, Cholesterol is a component of animal fat and it was not surprising that thedevelopment of atherosclerosis should be linked with diet and consumption of animalfats. Sthoulya (obesity) is a chronic disease, prevalent in both developed anddeveloping countries affecting children as well as adults. 01. The major health consequences with obesity are NIDDM, raised cholesterol, and hypertension. Coronary heart disease, gall bladder disease, psychosocial disturbances and certain types of cancer. These diseases are definitely associated with an increased risk of mortality. 02. Obesity is the mother of many degenerative diseases in adult life, where hyperlipidaemia is common and responsible for cardiovascular and cerebrovascular diseases. Prevention as control of this problem therefore, claims priority attention. 03. Ayurveda opines that there is no specific treatment for Sthoulya, hence it has been challenging medical problem from the Samhita period to this day. Hence, the above subject was selected with an aim of understanding the Subject in detail along with its management. 2 Introduction
  14. 14. Efficacy of Tryushanadya loham in Sthoulya Due to above reasons an attempt was made to suitable remedy forSthoulya mentioned in Charaka samhita and in all available Ayurvedic literatures. Thus,Thryushanadya loham yoga was taken,which yoga is praised in by yogaratnakara as aremedy for disease Sthoulya (Obesity). To evaluate the effect of Thryushanadya loham in Sthoulya with special referenceto Hyperlipidaemia, clinical trial was conducted on 30 patients with pre & post testdesign. All the patients received Tryushanadya Loham yoga for 60 days and followed byfollow up for 30 days. The total duration of the treatment was 90 days The lipid values and also sign and symptoms before and after the treatment werecompared. Totally five assessment were made to observe the effect in different stages. To assess the effect of the treatment, variables were subjected for student’s ‘t’test. The result of the clinical study showed Tryushanadya Loham Shamana therapyhas a role in Sthoulya (Hyperlipidaemia). 3 Introduction
  15. 15. Efficacy of Tryushanadya loham in SthoulyaHISTORICAL REVIEW Our ancient scripture Yajurveda quotes, “Oh God ! Give us a food which will keep usaway from diseases.” Charaka affirmed that in the beginning of Kritayuga people werecompletely disease free and Ojovan like Devatas as they were getting foods which rich inrasa, guna, veerya, and vipaka. As days passed some become rich and habituated to eat more,which lead to increase in body weight. This increase in body weight lead the disease freepeople of Kritayuga to the disease-full world. Thus, Medoroga is known since the times ofKritayuga and is one of the causes for the disease to develop. Two thousand five hundred years ago Hippocratus, noted that fat men “die suddenly”.This suggests not only the disease but also he knew the severity of the increased mortalityrate due to obesity.SAMHITA PERIODCharaka Samhita (Before 1000 BC) Increase of disease may be high during that period, hence they able to study thedisease clinically and mention the specific line of treatment, and many single andcompounds. Outstanding being the knowledge of genetic role in the etiopathogenesis.Sushruta Samhita (1000-1500 BC). Increased incidences might have forced them to find the root cause. So Sushrutaclarify quotes Rasa is the cause for both obese and lean.Astanga Hridaya (550 C A D) Discussed Sthoulya in Dwividhopakramaneeya and included it under Langhanatherapy. Treatment aspect of Sthoulya is discussed but states, as there is no medicine forSthoulya. 4 Roopa
  16. 16. Efficacy of Tryushanadya loham in SthoulyaMEDIEVAL PERIOD This period of history of Indian medicine is known as a period ofcommentators. Hence most of the books of this period are collections of thoughts of previousauthors, commentaries of previous works.Madhavakara (9 C AD) Madhavakara renamed Sthoulya as Medoroga and compiled the disease from theworks of previous authors. But change of nomenclature indicates, instead of consideringanatomical change i.e. Shareera Sthulata he wanted to consider physiological changes in thedisease condition.Chakrapani (11 C AD) The commentator of Charaka Samhita gives a critical commentary over it but he hasnot emphasized much about the disease in his own book Chakradatta.Dalhana (12 C AD) A commentator of Sushruta Samhita, clarify important queries by giving logicalanswers.Sharangadhara (13 C AD) Even-though mentioned the disease in roganana prakarana, not considered in hisexplanations.Bhavamisra (16 C AD) He specifies profuse sweating due to excess Medas creates a media for external germson the skin.Yoga Ratnakara (17 C AD) His views are almost similar to previous Acharyas, 5 Roopa
  17. 17. Efficacy of Tryushanadya loham in SthoulyaFew recent works done at different research centers are mentioned below. Effect of Turmeric extract on Lipid profile BY Deshapande U.R. and group, at Tata Memorial Hospital, Parel. Development of Hypolipidaemic agents from plants and Traditional remedies By Nityanand. S. at Central drug research Institute, Lacknow. Hypolipidaemic effect of Fenugreek seeds, BY Sharma. R.D. at P.G. Department S. N. Medical College, Agra. Effect of Prunus amygdylus seeds on lipid profile, By Sunita Teotia at Centre for Biomedical Engineering, IIT, Delhi. Hypolipidaemic activity of Eleven different pectins, BY Valsa A. K. at Department of Biochemistry, University of Kerala, Karivettam. Hypocholesterolaemia action of three Guggulu preparations, By Nair R.B. RRI, Trivendrum. Hypocholesterolaemic effect of Terminalia arjuna tree bark, BY P. Gupta, at Dept. of Pharmacology, SMS Medical College, Jaipur. Terminalia arjuna : an Ayurvedic cardio tonic, regulates lipid metabolism in hyperlipidaemic rates, by Kapoor N. K. at Div. Of Biochemestry, C.D.R.I. Lakhnow. Effect of boiled Barley rice feeding in Hypocholesterolaemic and Normolipidaemic subjects, By Tomia, M at National Institute of Health and Nutrition, Tokyo. Preliminary screening of Hypocholesterolaemic activity in Solanum indicum, By Badar, Y. at Pharmaceutical and fine Chemical Research Center, PCSIR Laboratory Complex, Karachi. 6 Roopa
  18. 18. Efficacy of Tryushanadya loham in SthoulyaHETU For a crystal clear picture of a diseased condition, it is necessary to be well versedwith the cardinal factors causing the medoroga (Obesity), which are five in number. They areHetu or Etiology, Purvarupa or Prodromal sings and symptom, Rupa or actual sign andsymptoms of the disease, Dosha samprapti the actual disease process or pathology occurringin the body, and Upashaya, Positive response with treatment adopted for diagnosing adisease. Among them Hetu, which literally means the causative factor has its own place ofsignificance. It is a fact highlighted by the assertion of ancient seers that Nidana parivarjana,removal of causative factors itself is treatment. A disease treated symptomatically tends torecur, it the causative factors are allowed to persist. Hence knowledge of nidana is a must.Comparative study of nidana according to different texts is given.Table1: Nidanas of Sthoulya by different authors as fallowsSl.N Nidanas Ch Su As BP MN Y.R 1 Shlesmala ahara - a - - a a 2 Guru, Madhura, Sheeta, Snigdha ahara a - a a - - 3 Adhika matra sevana a - - - - - 4 Adhyashana - a - - - - 5 Avyayama a a - a a a 6 Divashayana a a a a a a 7 Avyavya a - - - - - 8 Na chinta and shoka a - - - - - 9 Beeja swabhavaja a - - - - -Aharaja hetu 7 Roopa
  19. 19. Efficacy of Tryushanadya loham in Sthoulya Shleshmala ahara, guru, madhura, and snigdha ahara, adhika matra sevana andadhyashana all these come under aharaja nidana. Panchabhoutika level of their study revels. Guru - Prithvi and Jala Snigdha - Jala Sheeta - Jala Madhura - Prithvi and Jala Meda - Prithvi and Jala Kapha - Prithvi and Jala There by as a rule, a similar quality increases the quantity, the increase kapha andmedas. Ayurveda is not only very particular about quality but also about quantity and modeof taking food. Annapana vidhi, Matrashriteya, Drava Dravyavijnaneeya etc chapters arespecifically meant for this. Quantities of the food and jataragni are interdependent. It meansfood taken in a proper quantity only maintains Agni and this matra depends on Agni bala. Soadhika matra bhojana i.e. excess intake of food causes immediate aggravation of all thetridoshas. This leads to disease manifestation in the body. Adhyashana is intake of the foodbefore the completion of digestion of previously consumed food. Dalhana has clearly told, inthe presence of deeptagni also adhyashna produces ama and leads to the formation ofmadhura anna rasa, which in turn forms medovridhi. The term Obesity is derived from the Latin word “obsus” which means having eaten.Its very name suggests the root cause of obesity is over eating. Body needs 3000k cal/day tomeet basal needs, 500-2500 k k cal/day re required to meet the energy demands of dailyactivities, if consumed more than this (i.e. dhika matra sevana) leads to obesity especially 8 Roopa
  20. 20. Efficacy of Tryushanadya loham in Sthoulyafats and carbohydrates having more caloric value 9.3 kcal/g and 4.1 kcal/g respectivelybecomes the main cause for obesity.Viharaja hetu Avyayama, Avyavaya, Divashayana are categorised under Viharaj Nidana.References from the classics revels Vyayama is a must for a person who takes more fattyfoods, since it reduced fat. Importance of Vyayama is exaggerated by saying “one who doesregular exercise need not think of guruta and laghuta of the foods.” Contrary to this lack ofexercise or Avyayama along with guru ahara definitely lead to madovriddhi. Vyavaya is alsoa kind of physical work where in more calories is spent for one intercourse. If a person is notindulging in vyavaya dhatu kshaya will not take place instead it gives dhatupusti which leadsto medovriddhi. It is strictly advised for an obese person not to sleep in the day and less sleepeven in the night. Because walking in the night causes rukshata and daytime sleep increasessnigdhata that causes kaphavriddhi and leads to Sthoulya.Manasika hetu Achinta and shoka can be included under this heading Ayurveda considers manasikakarana also as an important entity for disease manifestation. Here is Sthoulya also harshanityatwa and Achinta and shoka that are manasika karanas definitely influence the Sthoulya.Mental disturbances cause vata vriddhi that indirectly causes dahtu kshaya where as prasannamanas always increases kapha hence becomes hetu of the Sthoulya.Beeja swabhava Charaka samhita is the only text in Ayurveda that explains beeja swabhava as acausative factor. Commenting over the word beeja swabhava Gangadhara and Chakrapanihave clearly told, “atisthula mata pitra sonitha sukra swabhavat which means the character of 9 Roopa
  21. 21. Efficacy of Tryushanadya loham in SthoulyaSthoulya is inherited from obese parents. Study also revels there is 50% of chance forchildren being obese when one of the parents is obese, this proportion rinsing to 75% withboth parents obese. Obesity runs in families. Further more, identical twins usually maintainweight leaves within 2 pounds of each other through out life, it they live under similarcondition. Or within 5 pounds of each other if there condition of life differ markedly, thismight result from eating habits engendered during childhood but it is generally believed thatthis close similarity between twins is genetically controlled.Hormonal cause Ayurveda is silent abut endogenous obesity Dr. Jeffrey’s Flier explains there is noestablished endocrine cause for most cases of obesity. However endocrinologists frequentlyare consulted because of concern that the patient may have cushing syndrome orhypothyroidism. Endocrine syndromes that may be associated with obesity are3 cushingsyndrome, Hypothyroidism, insulinoma, Craniopharyngioma, Turner syndrome, Malehypogonadism.Influence of dietetics in Pregnancy Disorders such as obesity, diabetes, cancer, heart disease etc are not only the result ofinheritance but also etiological factors. The new science of fetal programming suggests thatas pregnancy progresses, each month in the womb shapes our health for life. Under nutritionduring the fetus’s first trimester makes obesity more likely in adult hood, perhaps the appetitecontrol center in the brain programmed to over eat. One best evidence can be quoted here. Inworld war II Nazis tried to starve the population of western Holland from September 1944until the following may. Men who were fetuses during all or part of the period are studied. Iftheir mothers were starving during the first trimester from March to May 1945 but got 10 Roopa
  22. 22. Efficacy of Tryushanadya loham in Sthoulyaadequate food later delivered heavier, longer and with larger head babies than in normalperiod. As adults they were more likely to be obese. If their mothers went hungry only in thefinal trimester (born in Nov 1944) they were lean. It the food is scarce during the first trimester, the fetus develops a so-called thriftyphenotype. Its metabolism is set so that every available calorie sticks and scarcity of foodmay effect the appetite centers in the fetal brain, and sets as “eat whatever is around, younever know when famine will hit”.SAMPRAPTI 11 Roopa
  23. 23. Efficacy of Tryushanadya loham in Sthoulya The samprapti for the disease explains the method or process by which the vitiateddoshas reach the dooshyas and produce the anatomical and physiological changes in thetarget organs leading to expression as a disease. Usually this process follow a regular patternaccording to samanya siddhantas of Ayurveda that is why “Samyak prapti or vyadhi isknown as samprapti” Exceptionally in diseases like medoroga it differs from regularsamprapti. Hence deep study and detai9led analysis over pathogenesis of Medoroga carriesimportance. The samprapti of medoroga has been vividly described in almost all thetextbooks of Ayurveda. Views of all the authors goes on a similar line, accept AstangaSangrahakara, where he deviates a little. Absence of physical activity, sleeping during day and kaphakara aharas inducedmadhuryata to annarasa, which in turn increase the medas by its snigdha guna. This obstructsthe nutrients channels of the by its Snigdha guna. This obstructs the nutrients channels of theremaining tissue depriving them of nutrition. So only fat accumulates in large quantities inthe body. Because of obstruction, Vayu in kosta begins to act fast, increases the digestiveactivity rapidly, making voracious hunger an d craving for large quantity of food, just as theforest fire destroy the forest, the Vata and Agni destroy the body resulting into hypermetabolic activity. This samprapti of medoroga is confusing due to the Medoagni mandyata andformation of ama in presence of teekshnagni and where as successive dhatus are notnourished even the medas is over nourished. Hence here “Rasat Raktam tato Masam” theoryfails. Thus clarification at the level of process of pathogenesis is required. At this junctiondiscussion abut agni, dhatu poshana and ama concerned to Medoroga is essential.Jataragni 12 Roopa
  24. 24. Efficacy of Tryushanadya loham in Sthoulya In medoroga both the extremes of vitiated Agni can be seen at different levels.Mandagni, in the manifestation of the disease and teekshagni, in aggravating the condition. Inthe beginning none of the authors have specified about teekshagni, instead it is mentionedafter Medodhatu vriddhi. All the nidanas specified for Medoroga like excessive intake of, Guru, Sheeta aharasand not indulging in sufficient physical exercise are the supportive factors for the productionof Ama, which is formed due to hypo function of ushna. This ama or Madhura annarasa byits snigdha guna increases medas there by like other diseases here also mandagni is the rootcaused of the disease. After the accumulation of fat, teekshnagni play an important role.Vayu obstructed by Medas in kosta increased Agni under kumbakar pawan nyaya, makingfor voracious hunger and craving for large quantity of food. This Agni will be so strong andharmful if proper food is not supplied to it, it destroys body as fire destroys the forest.Dhatwagni In Medoroga a ling between Jataragni and Medodhatwagni is broken and thereforeeven when the function of Jataragni is good the functions of Medogni is not so. This isbecause whatever the outcome of the Ahar i.e. either pakwa rasa or ama rasa, it has to besupplied to all dhatus for their nourishment; in medoroga rasa is rich in snigdha guna, and issimilar to medas. There by it is supplied to Medodhatwagni, which increases the medodhatu.Agni and Ahara are interdependent. Ahara is the fuel for agni and agni bala depends on thematerial supplied to it for digestion. In medoroga excess quantity of ahara rasa is supplied toMedodhatwagni, which causes agnimandya and forms ama at medodhatu level.Dathu poshana in Medoroga 13 Roopa
  25. 25. Efficacy of Tryushanadya loham in Sthoulya Since ama represents the vitiated or deficiently formed ahara rasa of rasadhatu withpoor nutritional capacity, there is a disturbance in dhatu poshana. In Medoroga, medas isincreased abundantly. Hence there will be disparity between medas and other dhatus.Charaka accepts atimedovriddhi but not mentioned any cause for it. Sushruta tried to clarifyit and he tells remaining dahtus are not nourished because of Margavarodhata. Astangasangrahakara further gives the explanation as, the remaining portion of rasa dhatu being verylittle in quantity is not enough to nourish the raktadi dhatus and also quotes one samanyasiddhanta as “that which has undergone increase first will only undergo increase further andtells like vayudi fat also follow it, there by only Medo vriddhi is seen compared to otherdhatus. Dalhana divides dhatus as Poorvadhatu and Uttaradhatu and explainsundernourishment of uttaradhatu is due to Avruta marga and because of vishista aharavashat,Adrastavashat and Medasavruta margata, over sending Rakta and mamsa directly Medas isincreased. Hence poorvadhatu undernourishment is justified and present context. The specific nutrients of one dhatu are not channeled to any other dhatu. The portionof Ahara rasa meant to provide nourishment to a particular dhatu does not come in contactwith other dhatus. According to khalekapota nyaya, as there resting places attract pigeons,the sthayi dhatus attract their requisite nutrients from the Ahararasa through their specificdhatuvaha srotases and nourish themselves. Hence when Madhura annarasa rich insnigdhaguna moves through channels, nourish only medas and as ahararasa is having lessquantity of requisite nutrients of otherdhatus they are not properly nourished.Ama 14 Roopa
  26. 26. Efficacy of Tryushanadya loham in Sthoulya As both jataragni and dhatwagni are impaired in medoroga, production of jataragni ordhatwagnijanya ama is common. All the authors have used the word madhura annarasa.Vagbhata specially tells kapha mishrita annarasa acts as ama. Madhukosha commentary saysif annavaha srotas is coated with madhura annarasa that turns all the food into madhura.Sushruta tells, at the time of production of Pitta in annavaha srotas (ama vipaka), if food isconsumed it turns into vidhahi. As dalhana tells adhyashana sheelata is the cause forproduction of ama in presence of teevragni, there by it can be said during the time ofproduction of kapha in annavaha srotas (madhura vipaka), food is again consumed because ofadhyashanasheela that leads to the production of madhura annarasa or kaphamishritaannarasa. This avipakwa Rasa is known as ama. Now it is more appropriate to say, because of jataragnijanya ama dhatwagni isimpaired and dhatwagnijanya ama is formed. Proper conversion of poshakadhatu to poshyadhatus dose not takes place due to medoagni mandyata and more dusta medas is formed. Thismedodhatu being produced due to dhatwagni mandya is knows as samadhatu. Therebymedoroga is included under sama medodhatu janya vikaras.POORVA ROOPA 15 Roopa
  27. 27. Efficacy of Tryushanadya loham in Sthoulya The poorvaroopa of Medoroga are not specifically mentioned by any of the authors.The roopas mentioned for medoroga are - Increase in Medodhatu - Pendulum movements of buttocks, abdomen and breast - Lack of enthusiasm in physical activities - Disproportion growth of the body. However the general principle about poorvaroopa states that, “roopa of the vyadhiwhen found in Avyakta or alpa avastha is considered as poorvaroopa. So, medovriddhibefore to the pendulum movement of Spik, Sthana, Udara can be considered as Poorvarupa.Before the manifestation of the disease, Agni is depraved and once the medas startaccumulating, it turns into teekshagni. Similarly as kapha vriddhi is observed, lakshanas toldin kriyakalavastas of kapha are seen.ROOPA 16 Roopa
  28. 28. Efficacy of Tryushanadya loham in Sthoulya Roopa is the prominent diagnostic parameter of a disease. At this stage, DoshaDooshya Samuchhaya is completed & the onset of the diseases takes place, which gives thesymptomology of the disease. These sign & symptoms may change from time to timeaccording to the progress of the diseases. Certain symptoms may newly appear while somemay disappear. We cannot find all the symptoms in every patient at once unless the diseasesbecomes grave.Table2: Laxanas of Sthoulya by different authors as fallows.Sl.No. Laxana Ch Su AS MN BP YR01. Chala Spik Udara & Stana * - * * - *02. Kshudra Shwasa - * - * * *03. Ayasa - - * - - -04. Alpa Bala * - * - * -05. Ati Kshudha * * * * * *06. Ati Pipasa * * * * * *07. Ati Nidra - * * * * *08. Ati Swada - * * * * -09. Dourgandhya * * * * * *10. Moha - - - * * *11. Kratana - * - - * *12. Utsaha Hani * - * * - -13. Javoparodha * - - - - *14. Jadya - - * - - -15. Soukumaratva - - - * - -16. Krachhra Vyavayatva * - - * * *17. Gadgadatwa - * * - - -18. Alpa Ayu * - * * - * It is very interesting to study how these lakshanas are manifested. 17 Roopa
  29. 29. Efficacy of Tryushanadya loham in Sthoulya1. Chala Spik, Udara, Sthana Through the medas is spread throughout the body, its seats of accumulation areUdara, Spik, and sthana. Thus increased medas accumulates more at these places and leads topendulum movement of them.2. Kshudra Swasa Excessive fat accumulation in the abdomen interferes with the mechanism ofrespiration. Respiration act depends on the movement of the diaphragm. Because ofaccumulated fat, diaphragm fails to move up and down o the expected extent, hence pressurecreated during contraction phase will not be sufficient to expel out air from the lungs. Thisexcess carbondioxide present in the blood stimulate the respiratory center, which leads tokshudra swasa.3. Alphabala, Ayasa and Sukumarata The main function of medas is giving dridata and bala to the body. In Sthoulya wefind abundant medas but controversy to it we get symptoms like alphabala, ayasa,sukumarata. Chakarapani has commented over the word medodosha as dustamedas.Dustamedas cannot be expected to do its normal function i.e. dridatwa to the body and at thesame time poorva dhatus and uttardhatus of meda are undernourished. So all the sapta dhatudourbalya takes place which from the above said conditions.4. Atikshuda and Pipasa The increased fat obstructs the channels of vata. Vata then begins to act withinAmashya, increases the digestive activity, making for voracious hunger and thirst, which areappetitive mechanisms. 5. Kricchra Vyavaya 18 Roopa
  30. 30. Efficacy of Tryushanadya loham in Sthoulya Sthoulya rogi faces difficulty in intercourse because of two reasons. Foremost is undernourished shukra dhatu and on the other hand is the alpa bala or inability to perform any act. Proper quantity of shukra raised the feeling of enjoyment (arousal) contrary in shukrakshaya condition. After prolonged intercourse in shukra kshaya condition, instead of secretion of shukra, sarakta veerya is being secreted. This is definitely a difficult intercourse or kricchra vyavaya. Whole of this act needs utsaha, bala or ability, which is absent in medorogi. So it is a common symptom we find in Sthoulya rogi which disturb his mental state as well as sexual life.6. Alpa Ayu. Life is very important factor and body is like a driver for chariot. Ayurveda ismeant for maintenance and fulfilling the desire of long living. So leaving aside all otherthings body is to be protected. Since body is produced and maintained by food person shouldtake wholesome foods. Those who cultivate the habit of taking whole some food will notgives rise the victims premature death, loss of strength and enthusiasm. Where as medorogibecome a self-victim for his reduced longevity by adopting unwholesome food habits. Excessincrease of medas causes the dhatu kshaya of all other dhatus and is associated with anincreased incidence of cardiovascular, gall bladder diseases, diabetes, and other conditions,which are fatal important sings of increased mortality rate.7. Ati Nidra In obese patents excess sleep is commonly observed. Kapha, because of its increasedquantity, which is not undergoing regularity, obstructs the srotas. This srotorodha causesheaviness of the body, from heaviness follows laziness, which in turn causes excess sleep andlethargic ness in the body. 19 Roopa
  31. 31. Efficacy of Tryushanadya loham in Sthoulya8. Sweda and Dourgandha All classics consider atisweda and dourgandha as lakshanas of Sthoulya and furthergives explanations 1.By the presence of fat, at the origin of the channels of sweat increase insecretary activity and 2. Association of kapha makes profound increase of sweat.Contrary to this Charaka use the word swedabhadha and Chakrapani commenting over it as,“production of sweda is the function of meda where as in Sthoulya due to shleshma samsargathis produced seat is obstructed”. Gangadhara have also clearly commented swedabhadhameans “sweda is not excreted” So Charaka accepts the excess production of seat but he isdiffering from others by saying as it is not excreted out properly. Meda is having amaghandaby nature, in the presence of dusta medas in Sthoulya gives raise still worse odour. Excessproduction of sweat, which is the mala of meda, gives daurgandha in the body.9. Gadgadhatwa Gadgadhatwa means the “Avyakta vachanam” according Dalhana. Which meansstammering or unclear pronouncetion of word or even hoarseness of the voice, which is themore appropriate word to be considered.10. Krathana. Excess kapha obstructs pranavaha srotas resulting in krathana. In Ayurveda, eventhough all the above said lakshanas are explained for Sthoulya, a diagnostic key forconsidering a person as obese is given specifically. The person can be said as obese when hehas lack of enthusiasm in physical activities, disproportional to the growth of his body,intense increase in mamsa and meda, and has movement of the buttocks, abdomen andbreast. 20 Roopa
  32. 32. Efficacy of Tryushanadya loham in Sthoulya Parallel to this some more keynotes are available from modern concepts. A number ofdifferent criteria have been suggested to identity the obese person. Important among them arementioned here.1. Standard height and weight relation The most influential application of this approach has been through the use of lifeinsurance data that assesses mortality as a function of body weight per height, adjusted forframe size, with obesity defined on purely statistical grounds as a weight that is above theaverage weight for given height. The charts are given below:Table No. 3: Ideal weights for men Height (ft) Small frame (kg) Medium frame (kg) Large frame (kg) 5.2 50.8-54.4 53.8-58.5 57.2-64.0 5.3 52.2-55.8 54.9-60.3 58.5-67.1 5.4 53.5-57.2 53.2-61.7 59.9-67.1 5.5 54.9-58.5 57.6-63.0 61.2-68.9 5.6 56.2-60.3 59.0-64.9 62.6-70.8 5.7 58.1-62.1 `60.8-66.7 64.4-73.0 5.8 59.9-64.0 62.6-68.9 66.7-75.3 5.9 61.7-65.8 64.4-70.8 68.5-77.1 5.10 63.5-68.0 66.2-72.6 70.3-78.9 5.11 65.3-69.9 68.0-74.8 72.1-81.2 6.0 67.1-71.7 69.9-77.1 74.4-83.5 6.1 68.9-73.5 71.7-79.4 76.2-85.7 6.2 70.8-75.7 73.5-81.6 78.5-88.0 6.3 72.6-77.6 75.7-83.5 80.7-90.3 6.4 74.4-79.4 78.1-86.2 82.7-92.5Table No. 4: Ideal weights for women Height (ft) Small frame (kg) Medium frame (kg) Large frame (kg) 21 Roopa
  33. 33. Efficacy of Tryushanadya loham in Sthoulya 4.10 41.7-44.5 43.5-48.5 47.2-54.0 4.11 42.6-45.8 44.5-49.9 48.1-55.3 5.0 43.5-47.2 45.8-51.3 49.4-56.7 5.1 44.9-48.5 47.2-52.6 50.8-58.1 5.2 46.3-49.9 48.5-54.9 52.2-59.4 5.3 47.6-51.3 49.9-55.3 53.5-60.8 5.4 49.0-52.6 51.3-57.2 56.7-64.0 5.5 50.3-54.0 52.6-59.0 56.7-64.0 5.6 51.7-55.8 54.4-61.2 59.5-66.2 5.7 53.3-59.4 58.1-64.9 62.1-69.9 5.8 55.3-59.4 58.1-64.9 62.1-69.9 5.9 57.2-61.2 59.9-66.7 64.0-71.7 5.10 59.0-63.5 61.7-68.5 65.8-73.9 5.11 60.8-65.3 63.5-70.3 67.6-76.2 6.0 62.6-67.1 65.3-72.1 69.4-78.52. Body mass index A second approach for defining the obese state is body mass index (BMI). It can becalculated by using the formulaBMI = Weight in Kg Height in (meter)2Table No. 5: Optimal BMI values are given below 22 Roopa
  34. 34. Efficacy of Tryushanadya loham in Sthoulya Height Body weight in Kilogram (cms) 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 42.8 43.4 40.8 38.3 35.7 33.2 39.6 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 40.4 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 17.6 165 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 With BMI 25 to 30 are defined as over weight and of those in excess of 30 are defined as obesity. 3. Waist- to- hip ratio Recent evidence suggests that central obesity as judged by the waist to hip ratio is evident as many of the most important complications of obesity, including insulin resistance diabetes, hypertension and hyperlipidaemia are linked to the amount of intra abdominal fat, rather than to lower body fat (i.e. buttocks and leg) or subcutaneous abdominal fat. A waist- to – hip ratio for men is 0.9 while that for women if > 0.85 is ideal. Table 6: Waist measurement in cmsHip 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 23 Roopa
  35. 35. Efficacy of Tryushanadya loham in SthoulyaCms50 1.00 1.10 1.20 1.30 1.40 1.50 1.60 1.70 1.80 1.90 2.00 2.10 2.20 2.30 2.40 2.50 2.6055 0.91 1.00 1.09 1.18 1.27 1.36 1.45 1.55 1.64 1.73 1.82 1.91 2.00 2.09 2.18 2.27 2.3660 0.83 0.92 1.00 1.08 1.17 1.25 1.33 1.42 1.50 1.58 1.67 1.75 1.83 1.92 2.00 2.06 2.1765 0.77 0.85 0.92 1.00 1.06 1.15 1.23 1.31 1.38 1.46 1.54 1.62 1.69 1.77 1.85 1.92 2.0070 0.71 0.79 0.86 0.93 1.00 1.04 1.14 1.21 1.29 1.36 1.84 1.50 1.57 1.67 1.78 1.70 1.8675 0.67 0.73 0.80 0.87 0.93 1.00 1.02 1.13 1.20 1.28 1.41 1.40 1.47 1.61 1.60 1.67 1.7380 0.63 0.69 0.75 0.81 0.88 0.94 1.00 1.06 1.13 1.19 1.25 1.31 1.38 1.44 1.50 1.56 1.6385 0.59 0.65 0.71 0.76 0.82 0.88 0.94 1.00 1.06 1.12 1.18 1.24 1.29 1.35 1.41 1.47 1.5390 0.56 0.61 0.68 0.72 0.78 0.83 0.89 0.94 1.00 1.06 1.11 1.18 1.22 1.28 1.33 1.39 1.4495 0.51 0.56 0.63 0.68 0.74 0.79 0.84 0.89 0.95 1.00 1.05 1.11 1.16 1.21 1.26 1.32 1.37100 0.50 0.55 0.60 0.65 0.70 0.75 0.80 0.85 0.90 95 1.00 1.05 1.10 1.15 1.20 1.25 1.30105 0.48 0.52 0.57 0.62 0.68 0.71 0.76 0.81 0.86 0.90 0.95 1.00 1.05 1.10 1.14 1.19 1.24110 0.45 0.50 0.55 0.59 0.64 0.68 0.73 0.77 0.82 0.86 0.91 0.95 1.00 1.05 1.09 1.14 1.18115 0.43 0.48 0.52 0.57 0.61 0.65 0.70 0.74 0.78 0.83 0.87 0.91 0.96 1.00 1.04 1.09 1.13120 0.47 0.46 0.50 0.54 0.58 0.63 0.68 0.71 0.76 0.79 0.83 0.88 0.88 0.98 1.00 1.04 1.08125 0.40 0.44 0.48 0.52 0.56 0.60 0.64 0.68 0.72 0.76 0.80 0.84 0.85 0.92 0.96 1.00 1.04130 0.38 0.42 0.46 0.50 0.54 0.58 0.62 0.65 0.69 0.73 0.77 0.81 0.81 0.86 0.92 0.96 1.00135 0.37 0.41 0.44 0.48 0.52 0.56 0.59 0.63 0.67 0.70 0.74 0.78 0.79 0.85 0.88 0.93 0.96140 0.36 0.39 0.43 0.46 0.50 0.54 0.57 0.61 0.64 0.68 0.71 0.75 0.76 0.82 0.86 0.84 0.91145 0.34 0.38 0.41 0.43 0.48 0.52 0.55 0.59 0.62 0.66 0.69 0.73 0.75 0.78 0.81 0.83 0.88150 0.33 0.37 0.40 0.41 0.46 0.50 0.54 0.57 0.60 0.64 0.67 0.70 0.74 0.77 0.80 0.81 0.84 CLASSIFICATION OF MEDOROGA Supporting references from the classics are not available to discuss the types of medoroga. Astodareeya Adhyaya of Charaka, Rogagnana Prakarana of Sharangadhara specially deal with types of disease. Charaka have not mentioned Modoroga in his Astodareeya chapter where as Sharangadhara clearly said Medoroga is of only one type. Though the description of Medoroga/Sthoulya is mentioned in most of the classical texts like Charaka samhita, Sushruta Samhitas, Astanga Sangraha, Bhavaprakasha, Madhava nidana, Yoga Ratnakara, Chakradatta etc., but none of the author have classified Medoroga. 24 Roopa
  36. 36. Efficacy of Tryushanadya loham in SthoulyaVitiation of doshas may take place at the level of samprapti but ultimately meda dhatu is theonly one that has to be increased, to consider the condition as Medoroga. This may be thereason for not making any types in it. Hence it can be said that according to Ayurvedamedoroga is of only one type. But for the convenience of study it can be classified as following.Type 1 1. Aharajanya - Cosnuming Snighdadi Ahara, Adhyashana, Atimatra sevan etc, 2. Viharajanya - Diwaswapna etc, 3. Manasika Janya – harsha nityatwa etc. 4. Beeja swabhava – heredity.Type 2 1. Sahaja - Beejaswabhava 2. Janmottaraj – Ahara, Vihara and Manasikakarana janyaType 3 1. Sandhya medoroga – navotpanna, Alpalakshanayukta 2. Asadhya Medoroga – Puratna Upadravayukta Beejaswabhavaja etc. In modern text we find classification of obesity asType I 1) Exogenous – this is more common and due to excessive caloric intake. Here uniform distribution of fat with little execs under chin and abdomen is seen 25 Roopa
  37. 37. Efficacy of Tryushanadya loham in Sthoulya 2) Endogenous- here endocrine factors are at fault and obesity occur in spite of small caloric intake.Type II Depending on the distribution of fat this classification is made. 1. Generalised type – uniform distribution of fat. 2. Centr4al or trunk – at trunk and neck 3. Superior or buffalo – at face, neck, arms and upper part of trunk 4. Inferior at lower trunk and legs 5. Girdle – at hips, buttocks, abdomen 6. Breeches or trochentric- only buttocks 7. Lipomatous- localized deposits of fat over body.Type III 1. Hypertrophic obesity – increase in amount of fat per fat cell. 2. Hyper plastic obesity – increase in number of fat cells.SADHYASADHYATA Before starting the treatment of any disease it is essential to know whether thatparticular state of the disease is curable or incurable. Almost all the texts consider Sthoulyaas kasta sadhya when compared with treatment of krishatwa. But Vagbhata goes to an extentof saying there is not treatment for Sthoulya; neither Brimhana therapy nor Langhana therapyare sufficient to control excessive fat accumulation and to decrease agni and Vata. Inducommenting over it states, brimhana therapy given to a obese person will decrease agni and 26 Roopa
  38. 38. Efficacy of Tryushanadya loham in SthoulyaVata but not the medas, where as Langhana therapy will decrease medas but increases agniand Vata. So treatment is very difficult. Modern texts say successful treatment of obesity means sustained attainment ofnormal body weight and composition without producing unacceptable treatment inducedmorbidity, is rarely achievable in clinical practice. Medoroga can be considered as kasta sadhya, if it is navotpanna, having lessintensity, and without complications.UPADRAVA Complications appearing after the manifestation of the Prime disease and which aredifficult to treat are termed as upadravas. Agni sand vata, in their aggravated state causemany of upadravas in Medoroga.Table No. 7 : Upadravas of Sthoulya by different authorsSl.No. Upadravas Ch Su AS BP MN YR 1 Vata pitta Vikara a - - - a - 27 Roopa
  39. 39. Efficacy of Tryushanadya loham in Sthoulya 2 Prameha Pidika - a a - - - 3 Jwara - a a a - a 4 Bhagandara - a a a - a 5 Vidradhi - a a - - - 6 Vatavikara - a - - - - 7 Udar roga - - a - - - 8 Prameha - - a a - a 9 Urustambha - - a - - - 10 Kushta - - - a - - 11 Visarpa - - - a - a 12 Atisara - - - a - a 13 Arsha - - - a - a 14 Shleepada - - - a - a 15 Apachi - - - a - a 16 Kamala - - - a - a 17 Jantavo Anavaha - - - a - -Key : a = Present - = Absent It is clearly mentioned, increased medas cause profuse sweating and bad odour of theskin, which creates a media for production and survival of germs (anu jantus). There bymany of of the skin diseases like kusta, visarpa etc are seen as upadravas and atiswedamentioned as poorvarupa for kusta. Impairment of Medovaha srotas in medoroga may lead tothe disease Prameha and prameha pidika. 28 Roopa
  40. 40. Efficacy of Tryushanadya loham in Sthoulya Ama condition present in Sthoulya may lead to urustamba, atisara, jwara etc. theetiological factors viz Avyavya, Avyayama, diwaswapna are similar to both Medoroga andArsha. These factors are increased more because of inactive nature of obese person, whichprobably leads to arsha. Obstruction of swedavaha and ambuvaha srotas leads to udara, asexcess medas obstruct the srotases, this condition may arise as upadrava in obese person.Vata get aggravated because ofobstruction and give rise many of the vata vyadhis asupadravas.Modern concept Obesity has psychological, behavioral and medical consequences; the nature andseverity of which are influenced by the degree of obesity. The common pathologicalconsequences of obesity are discussed here.Non-insulin dependent diabetes - Obesity is major risk factors for NIDDM and as many as 80% of patents withNIDDM are obese.Cardiovascular Disease – Epidemiological studies reveal that obesity is associated with an increased mortalityand morbidity from cardiovascular disease. Increased mass of tissues result in increasedcardiac work. Blood volume, stroke volume and cardiac out put are all increased. Obesity isalso associated with an atherogenic lipid profile.Pulmonary disease - The increased metabolic rate in obese subjects increases oxygen consumption andCO2 production, and these changes result in increased minute ventilation. In subject’s withmarked obesity, compliance of the chest wall is reduced, the breathing is increased and the 29 Roopa
  41. 41. Efficacy of Tryushanadya loham in Sthoulyarespiratory reserve volume and vital capacity are reduced, a resultant mismatch betweenventilation and perfusion may result in hypoxemia. Severe obesity may causehypoventilation, defined by the development of CO2 retention.Gall stones – Obesity is associated with enhanced billiary secretion of cholesterol. This results insuper saturation of bile and a higher incidence of gallstones.Endocrine consequences – Many changes injunction of Thyroid, Gonadal, Adrenal and Pituitary functions can beseen in patients with established obesity.CHIKITSA Ahara Even-though the disease is Santarpanajanya; langhana is contraindicated 1 as itincreases the vata that is the prime cause for the Medoroga. There by if the food is notsupplied timely aggravates agni & creates many disturbances in the body. Keeping this inthe mind, dietetics has to be planned in such a way that ahara should be guru for agni but at 30 Roopa
  42. 42. Efficacy of Tryushanadya loham in Sthoulyathe same the time it should cause Apatrapana. Many of the Aharadravyas are advised on thisline, which are mentioned in Pathyapathya. Many of the experimental studies have been doneon the fasting & the inference is that during the period of fasting, the blood pressure goesdown, ketosis & hyperureceamia occurs. Thus it is advised to undertake prolonged fastingprogramme under medical supervision. So instead of advising for langhana it is better tofollow the classical treatment which explains to Agni, which does not cause Santarpana. Italmost sounds similar to more quantity but less calorie diet. Diet for obese person should be planned that the body weight get about 50 – 60 gm.of protein per day, which is necessary for maintaining nitrogen balance in the body, 100 gmof carbohydrate, 40 – 50 gm. of fat. This proportion of protein, carbohydrate & fat has to bemaintained which otherwise disturbs the metabolism. The total calories allowed to anindividual will depend upon the present weight, activity levels of the patient. Vihara Vyayama, Vyavaya, Anidra, Chinta, Shoka, Shrama, Gamana are the vihara roopatreatment mentioned in the classics. Lacks of the factors are mentioned as for Stholya.Hence, we can say this is one of the nidana parimarjana line of the treatment. Regularexercise is recommended as an important component of all obese management regimens. Exercise help a person to spend energy & reduce his weight; & increases the basalmetabolic rate of the body which in turn burns away the excess fat & benefits in lipidabnormalities. An exercise improves the muscle tone & remove wrinkles & flabbiness of theskin. Simple walking or exercise, when energy worth 3500 calories is spent, the weight isreduced by 1 pound. Table below show energy spend in different types of the physicalactivity. 31 Roopa
  43. 43. Efficacy of Tryushanadya loham in SthoulyaTable No. 8 : Type of Physical ActivitySl.No. Type of Physical Activity Energy spent per minute01. Sitting, Standing, Reading, Writing 1.502. Driving Car, Tailoring 2.003. Household chores 2.204. Gardening 5.005. Walking 5 km/hr. speed 3.006. Fast walking speed 9 km/hr. speed 9.007. Light exercie of yoga 4.008. Cycling (Depending upon speed) 3.5 – 8.009. Table tennis 5.510. Games like Kho-Kho, etc. 8.011. Lawn tennis 6.012. Dancing 5.013. Swimming 3 km / h. speed 9.014. Skipping 7.015. Running (Depending upon speed) 10 – 2516. Heavy exercise 8.0Aushadhi: This can be discussed under two headings 1) Shodhana 2) ShamanaShodhana Under the shodhana we can consider Rookshna Udwarthana, Snana, Lekhana Basti,& Shodhana.The general term shodhana is used by Vagbhata which indicates all thepanchakarmas. But when we see the Dosha & contraindications of Panchakarma it reveals – Snehana – As a general rule Snehana should not be administered in medoroga. But tila taila prayoga is indicated in Medoroga. It may be 32 Roopa
  44. 44. Efficacy of Tryushanadya loham in Sthoulya because of its Sukshma & Vyavayi through which it opens the Medoavritha Srotas & Ushna guna of it reduces the kapha. Swedana – Swedana for obeses patient is contraindicated but if essential mrudu sweda is adviced Vamana – Not ondicated in Shoulya where as in conditions like Amadosha & Kapholbana vamana can be adviced with Yastimadhu. Virechana – Not indicated but with special precautions can be used. Basti – Lekhana Basti is indicated. Nasya & Raktamokshna – Clear- cutindication is not available.Shamana Eventhough Meda, Vata & Kapha Nashana is said as Chikitsasutra , the drugplanned should have Deepana & Pachana property to enhance Agni & Amapapaka. Asobstruction of srotasa is main factore in medoroga, the drugs must have Rookshna &Chedana property to produce srotovishodhana. Along with these Ati teekshna, ushna,rooksha, guna dravyas are adviced as they are opposite to manda, snigdha & sheeta gunas ofkapha & meda. These by they subside Meda & Kapha.Five types of fat reducing drugs are used in modern sciences. Anti appetite Drugs reducing the level of sugar in the Metabolic stimulants Laxative drugs 33 Roopa
  45. 45. Efficacy of Tryushanadya loham in Sthoulya DiureticsAnd surgical treatment is also advised in the treatment of obesity as lipo suction. 34 Roopa
  46. 46. Efficacy of Tryushanadya loham in Sthoulya The disease obesity considered under the metabolic disorder. Metabolism refers allchemical processes in living beings producing energy and growth. The changes which occurin the digested food stuffs time of ingestion till the elimination in the form of excretion, thesum of total chemical changes which takes place within the body is to be considered asmetabolism which yields energy and enriches growth. As obesity is deposition of fat in thebody, it is justified to be under the heading of metabolic disorders. Origin of the body fat is from fats, carbohydrates and proteins in the food. Thecarbohydrates and proteins consumed in excess are converted into fats through the citric acidcycle. Hence study of metabolism of carbohydrate, protein and lipid are essential in thisregard.Carbohydrates Carbohydrate metabolism takes place under three headings- Supply, Storage & utility.Supply is regulated through the diet temporary storage in liver and utility by the cell & tissue& muscles. Absorption of glucose takes place mainly into the capillaries of the smallintestine. These capillaries take the contains into the portal circulation to the liver. The liver cells take the glucose from the blood and convert into the glycogen whichstored in the liver cells. The sugar stored in the liver as a glycogen is converted as a glucosewhenever needed it is released into the blood stream which will be taken up by the musclesand the other tissues. The maximum storage of the glycogen in the body is about 400 gms.Protien Proteins are hydrolised into the amino acids after digestion and absorbed by the villiand through the portal circulation enter the liver. The tissues select some of these substancesand in each organ either synthesized into new tissues or used to maintain and repair tissues.Amino acids not used in synthesis are broken down or diminished in the liver. In demisation,the amino groups are removed from amino acids molecules. The non-nitrogenous portion ofthe amino acid molecules is oxidized to liberate energy or is synthesised in to glycogen orfat. Therefore this portion of the amino acid molecule may be regarded as a source of energy. 34 Lipids
  47. 47. Efficacy of Tryushanadya loham in SthoulyaLIPIDS Lipids may be defined as compounds, which are relatively insoluble in water, butfreely soluble in organic solvents like benzene, ether, chloroform, etc. Lipids constituted aheterogeneous group of compounds of biochemical importance. They are found in the membranes, which maintain the integrity of cells & allows thecompartmentalization of cytoplasm in to specific organelles. Lipids function as a major formof stored nutrients (TGs), as a precursor for adrenal & gonadal steroids & bile acids(cholesterol) & as an extra cellular & intra cellular messenger (prostaglandins). Lipoproteinsprovide a vehicle for transporting the complex lipids in the blood as water – solublecomplexes & deliver lipids to cells through out the body.Classification of Lipids Lipids are classified into simple lipids, compound lipids, derived lipids &miscellaneous one. A. Simple Lipids : Esters of fatty acids with various alcohols i) Neutral fats ii) Waxes B. Compound Lipids Esters of fatty acids containing groups other than & in addition to an alcohol & fatty acids. i) Phospolipids ii) Glycolipids iii) Sulpholipids iv) Aminolipids v) Lipoproteins C. Derived Lipids Derived lipids obtained by hydrolysis of those given in those group A & B which still possesses the general characteristics of lipids. i) Fatty acids ii) Monoglyceriods iii) Alcohols 35 Lipids
  48. 48. Efficacy of Tryushanadya loham in Sthoulya D. Miscellaneous i) Aliphatic hydrocarbons including iso-octa-decome ii) Carotenoids iii) Squalence iv) Vit. E & K.Fatty Acids Fatty acids may be defined as an organic acid that occurs in a neutral TG & aremonocarboxylic acid ranging in chain length from 6-24 carbon atoms. In human body freefatty acids are formed only during metabolism due to hydrolysis of fat.Fatty acids A. Depending upon no. Of Carbon atoms i) Even Chain i.e., having 2-4-6 carbon atoms ii) Odd chain i.e., having 3-5-7 carbon atoms B. Depending length i) Short chain 2-6 carbon atoms ii) Medium chain 8-14 iii) Long chain 16 & above (24) C. Nature of hydrocarbon chain i) Saturated fatty acids ii) Unsaturated fatty acids a) Mono unsaturated b) Polyunsaturated iii) Branched chain FA iv) Hydroxy FA v) Cyclin FAThe lipids in the body physiologically exist in two forms – a) Element constant or structural lipids. b) Element variable – stored lipids. Elements constant is a part of the essential structure of the cells. The organelles arecomposed of macromolecules of lipids & protein, the lipid is mainly phospholipid. The 36 Lipids
  49. 49. Efficacy of Tryushanadya loham in Sthoulyaamount in the body between 0.5 to 1 kg & is independent of the state of nutrition. Cholesterolis another lipid present in cell membranes; it has also an important role in the blood. Element variable lipid, which is stored in the body, is in excess. The amountfluctuates & it is composed mainly of TG also called as neutral fats. Thus fat is chieflycomposed of glyceriods of various fatty acids & usually contains 75 % of oleic acid, 20 %palmitic acid 5 % stearic acid. Traces of lacithic & cholesterol as well as little amount ofPUFA are also present. The deposition of fat takes place adipose tissue.Dietary Fat Ghee & Ginger oil is two major dietary fats in India & is pure fats with no proteincomponents. In a diet with both plant & animal foods the absorption of fats are 90% whilethe carbohydrate & proteins are 90% while the carbohydrate & proteins are 90%. The dietary fat, despite being a source of energy, vitamins & EFAs improves thepalatability of food & helps to reduce the bulk of food is starchy ones absorbs a lot of waterduring cooking. A comprehensive review of the effects of cooking on proteins, carbohydrates& fats by Lans (1970’s) indicating that this subject is of little importance, but one which thefood technologies should be informed, the percentage of composition of these two dietaryfats are like this.Table9: Percentage of composition of dietary fats C4- C11 C14 C16 C18 Oleic Linolenic ArachidonicButterfat 11 08 26 11 33 38 0.4Sesame oil ---- ---- 08 04 45 41 ----The dietary need for fat The exact human requirement of fat is unknown. But a desirable range is with at least15 gms of vegetable fats totally accounting, not more than 30 % of daily caloric requirementas recommended by ICMR Nutritional expert’s group. The Institute of health, USA has also recommended intake of cholesterol less than300mg/day & increase in the poly-saturated fatty acids contents but more than 10%. The daily requirements of fats are normally by other nutrients. But there are manyexperiments conducted in past years proving that the level of blood lipids is also determined 37 Lipids
  50. 50. Efficacy of Tryushanadya loham in Sthoulyain part by the nature of dietary carbohydrates (90%) each. In healthy individuals intestine canabsorb up to 300gms of fats. Normally fats never form more than 10% of the dietary intake.With the fat intake more than 100mg/day or less, the presence of more than 7 gms of fat inthe feces constitute an evidence for fat absorption, (if found) at least for 5 consecutive days. Grain or less in tissue mass is determined by net balance between calories intake &caloric expenditure. Half of the normal diet intake is spend for basal process. Active personspends 40 % in physical activity, athletes – 50 %. In non-obese non-sedentary subjects 10%of indigestion calories are related as heat associated with absorption of food for dietarythermo genesis. So on estimating caloric requirements, physical activity, body size, composition, age,ex, physiological state, climate & environment are to be taken into consideration. A typical South Indian diet will be based on plain rice having 504 gm/2 servings at arate of 118k cal/100 gms. The average intake of dietary fats, milk products, and meat,fishless in the whole India is 17 gms, 69 gms respectively.PLASMA LIPOPROTEINS The plasma lipoproteins are the molecular complexes of lipids & specific proteins calledAdipoproteins. Theses dynamic particles are in constant state of synthesis, degradation &removal removal from the plasma. The lipoprotein particles includes – Chylomicrons (CM) Very Low Density Lipoprotein (VLDL) Low Density Lipoprotein (LDL) High Density Lipoprotein (HDL) Lipoprotein functions both to keep lipids soluble as they transport them in plasma &to provide an efficient mechanism for delivering their lipids contents of the tissues. Inhumans, the delivery system is less perfect than in other animal, as a result, humansexperience a gradual deposition of lipids especially Cholesterol in tissues. This is apotentially life threatening occurrence when the lipid deposition contributes to plaqueformation causing narrowing of blood vessels – known as Atherosclerosis. 38 Lipids
  51. 51. Efficacy of Tryushanadya loham in SthoulyaComposition of plasma lipoprotein The principle lipids carried by the lipoprotein particles are triglycerols & Cholesterol(free or esterified), obtained either from diet or de-novo synthesis. Lipoproteins are composed of a neutral lipocore surrounded by a shell ofapolipoproteins, phospolipids & non esterified Cholesterol all oriented so that their polarportions are exposed on the surface of the lipoproteins, thus making soluble in aqueoussolutions.I. Size & Density of Lipoprotein Particles The chylomicrons are the lipoprotein particles lowest in density & largest in sizecontain the most lipids & smallest percentage of protein. VLDLs & LDLs are successivemore dense, having a higher content of protein & lower content of lipid. HDL particles arethe most dense of the plasma lipoproteins.II. Apolipoproteins The apolipoproteins associated with lipoprotein particles have a number of diversefunctions including serving as structural components of the particles, providing recognitionsites for cell-surface receptors & serving as activators or co-enzymes for enzymes involvedin lipoprotein metabolism. Apoproteins are derived by structural & functions into classes Ato H with the most classes having subclasses.Chylomicrons These are the major exogenous lipoprotein synthesized in the intestinal mucosal cellsfrom the products off lipid digestion. Hey are large complexes rich in the Triglyceriodes. Theparticles enter the lactates in the intestinal villi & are transported via the thoracic duct to theblood stream. In the lymph & blood, the chylomicron particles acquiring apoprotein C & Efrom HDL. As they pass through peripheral capillary beds of hydrolysed by adipose tissue &skeletal muscle, their triglycerides are hydrolysed by apoprotein CII activated lipoproteinlipase, an enzyme bound to the endothelial surface, releasing fatty acids & glycerols. The results cholesterol rich chylomicron remnant with its apoprotein B & E isrecognized by specify receptors on the hepatic parenchymal cells & is rapidly cleared fromthe plasma. Glycerol enters the liver to be converted to glucose or used for synthesis ofTriglycerides. 39 Lipids
  52. 52. Efficacy of Tryushanadya loham in Sthoulya Thus chylomicrons are the transport from the transport from of dietary triglycerides tobe delivered to adipose tissue for storage & muscle for storage & muscle for its energy needs.Hence chylomicrons paricles are not considered to be atherogenic. The atherrogenic potentialof chylomicron remnants is a matter of dispute.VLDL These lipoprotein are the major carries of endogenous Triglycerides. They aresynthesized in the liver from glycerol & fatty acids & incorporated into VLDL along withhepatic cholesterol, Apo B, C, E. Apoprotein B100 & E are required structural componentsfor this secondary process. In the fasting state, majority of plasma Triglyceriods are carried inthis particles. The VLDL is secreted into blood stream grains more apoC from HDL. When theyreach the peripheral tissue, they are acted upon by the lipoprotein lipase liberating fatty acidsthat are taken up by the muscle. The VLDL remnant is now designed as IDL (IntermediateDensity Lipoprotein) & contains TG. Cholessterol, apo-B & E. Part of the IDL is taken up bythe Liver. A major fraction of IDL further loses Triglycerides & gets converted into LDL. Normally VLDL is probably not atherogenic. The smaller & more cholesterol richVLDL remains appear to have atherogenic potential. Persons with the genetic disorderfamilial dysbeta lipoprroteinaemia have accelerated atherosclerosis. Although elevation ofplasma triglyceriodes are common in patients with CHD, they are not uniformely predictorsfor CHD risk.LDL The LDL molecules are cholesterol rich lipoprotein molecules containing only Apo-B(B-100). Most of the plasma cholesterol is incorporated into LDL particles. Being small insize they can infiltrate through arterial walls & have a longer life than others. LDL receptorsrecognize the apo-B & apo-E & can there fore take up LDL or IDL. Once the LDL particlesbinds to the cells, they are internalized & cholesterol is related into the cells. Most of thecholesterol metabolized into in to steroid hormones. There is a cellular feed back regulating mechanism which inhibits intra cellularsynthesis of cholesterol when extraneous cholesterol is taken up from LDL. When thecellular cholesterol pool is increased, further uptake is also preventing by decreasing thesynthesis of the LDL or cholesterol & removes & removes cholesterol through bile. 40 Lipids
  53. 53. Efficacy of Tryushanadya loham in Sthoulya The cholesterol which is thus excreted into the intestine is partly reabsorbed (30-60%). The rest is excreted as fecal sterols, caprostanol & cholesterol after bacterial action.the liver also controls body cholesterol pool by converting to bile acids. Excess intracellular cholesterol can lead to 3 metabolic events. a) Inhibition of HMG –CoA reductase, the rate limiting step in cholesterol synthesis. b) Activation of enzyme Acylcoenzyme A cholesterol acyl Transferase (ACAT) which estrifies cholesterol for storage. c) Inhibition of production of additional LDL receptors, there by reducing cellular uptake of plasma cholesterol. Individuals with homozygous or heterozygous familial hypercholesterolemia can haveabsent diseased or defective receptors. Undiscovered abnormalities or numbers LDLreceptors & Apo-B maay be causal in the majority of patients with CHD. When the LDL levels in the plasma becomes become excessive they are removed by themacrophages of reticulo endothelial system in the scarvenger pathway. Macrophages seatedin the arterial wall eventually become over loaded with cholesterol ester & the converted intothe foams cells that characterized early atherosclerosis. Because the majority of plasmacholesterol (60-75%) is carried in the LDL particles, elevation of the total usually reflectsincreased LDL levels. The anatomical degree of coronary atherosclerosis has been directlylinked to the concentration off LDL.HDL The HDL mainly plays an important role in the transport of cholesterol fromperipheral tissue to liver. The only excretory route of cholesterol from the body is bile. HDLis synthesized mainly in the hepatic cells & intestinal cells & is seen as complexes of Apo A& Apo E with phospholipids. The cholesterol derived from peripheral tissue & otherlipoproteins are esterified in HDL because it has a LCAT activity. After esterification, theesterification, the ester from of cholesterol maay be transferred to other lipoprotein &transported to liver. A small portion of esterified cholesterol is stored in the case of HDL alsoacts as a carrier of Apo-C to be derived to the Triglyceride rich lipopprotein like VLDL &chylomicrons. HDL is protective, but low HDL concentration < 30mg/dl is a potent risk forCHD. HDL appears to expert a protective influence by removing cholesterol from tissues.Total body cholesterol is inversely related to HDL levels. 41 Lipids
  54. 54. Efficacy of Tryushanadya loham in Sthoulya Important functions of lipoproteins Chylomicrons transported mainly TG & smaller amounts of plasma lipoproteins, cholesterol esters & fat soluble vitamin from intestine to liver & adipose tissue. The lipids carried by chylomicrons principally dietary lipids. VLDL transported mainly “Endogenous TG” synthesized in hepatic cells from liver to extra hepatic tissue including adipose tissue for storage. High carbohydrate intake, high ratio of insulin/glucogen, high plasma free acids & alcohol intake increase the hepatic synthesis of both TG & VLDL so that enhanced amount of fatty acid reaching the liver is speedily mobilized in VLDL to adipose issue. LDL rich cholesterol esters transports cholesterol & its estrs from hepatic cells to extra hepatic tissues. LDL also regulates cholesterol synthesis in extra hepatic tissue, as regulates cholesterol delivered by LDL to cells inhibits HMG-CoA reductase, the rate limiting enzyme for cholesterol synthesis. HDL transports cholesterol & its esters from peripheral tissue to liver for its catabolism. Apo-D of HDL3 functions as the cholesterol ester transfer protein. Albumin FFA complexes transport mainly FFA, released by adipose tissue lipolysis & small amounts of lysophospholipids from extra hepatic tissues to the liver. Certain apoprotein can act as activators/inhibitors of specific enzymes.CHOLESTEROL AND LIPOPROTEIN METABOLISMExogenous Pathway Exogenous lipid transport being with intestinal incorporation of dietary triglycerides& cholesterol into large lipoprotein particles called chylomicrons (diameter, 80-500 nm.),which are secreted into the lymph & subsequently enter the blood stream. Whenchylomicrons reach the capillaries of adipose tissue & muscle, they are digested by anenzyme lipoprotein lipase, which is bound to the surface of the endothelial cells. Lipoproteinlipase hydrolyses the triglycerides in the core of the chylomicrons, & the liberated fatty acids 42 Lipids
  55. 55. Efficacy of Tryushanadya loham in Sthoulyacross the endothelium & enter the underlying adipocytes or muscles cells, they are then eitheresterified again to form triglycerids for storage or oxidized to provides energy. After most of the triglycrides have been removed in this fashion, the chylomicrondissociates from the capillary endothelium & enters the circulation again. Its size has beenreduced & its contents of triglycerides diminished, but its cholesterol esters remain intact.The particle is now designated as a chylomicron remnant (diameter 30-50 nm.). When the remnant reaches the liver it is cleared from the circulation by a receptorthat recognizes two of its protein components, apoproteins E & B-48. The receptor boundremnant is taken into the hepatic cell by a process termed receptor mediated endocytosis.Within the cell the remnant is digested in lysosomes, & the cholesterol esters are cleaved togenerate free cholesterol. The free cholesterol has several fats; it can be used for membranesynthesis, it can be stored esters, it can be excreted into the bile acids, or it can be used toform endogenous lipoprotein that are secreted into the plasma.Endogenous pathway – Endogenous lipid transport begins when the liver secretes triglycerides & cholesterolinto the plasma in very-low-density lipoproteins (VLDL: diameter, 30-80 nm.). The majorstimulus for such secretion is a high-calorie intake especially a high-carbohydrate intake),while induces the liver to assemble Triglycerides for export & storage in adipose tissue. TheTriglycerides of VLDL are cleaved in capillaries by the same lipoprotein lipase that digestlipoprotein lipase that digests chylomicrons. Digestion produces a VLDL remnant that is designated as intermediate-densitylipoprotein (IDL: diameter, 25-35nm.). After release from the endothelium, the IDL particleshave two metabolic fates. Some of the particles are cleared rapidly by the liver, again byreceptol-mediated endocytosis. The receptor that acts on the IDL particle is called Lowdensity Lipoprotein (LDL) receptor. It binds lipopretein that contains apoproteins thatcontain apoprotein E or B – 100 & it therefore interacts with both IDL & LDL particles. About half of the IDL particles are not cleared rapidly by the liver. Rather theyremain in the circulation, where most of the remaining Triglyceriods are removed, & thedensity of the particle increase further, until it becomes LDL (diameter 18-28 nm.). LDLcirculates for a relatively long time in man (half-life of about 1.5 days ). 43 Lipids
  56. 56. Efficacy of Tryushanadya loham in Sthoulya The particles are eventually degraded by binding to LDL receptors in liver &certainextra hepatic tissues. Circulating LDL constitutes the major reservoir of cholesterol in humanplasma, accounting for 60-70% of the total. When liver or extrahepatic tissues requirecholesterol for the synthesis of new membranes, steroids hormones or bile acids, theysynthesize LDL receptors & obtain cholesterol by receptor mediated endocytosis of LDL.Conversely, when tissues no longer require cholesterol for cell metabolic purposes, theydecrease the synthesis of LDL receptors. As cells of the body die & as cell membranes undergo turnover, free cholesterol iscontinually released into the plasma. This cholesterol is immediately absorbed into highdensity lipoproteins (HDL : diameter, 5-12 nm.) & in this location it is esterified with a long-chain fatty acid by an enzyme in plasma, lecithin: cholesterol acyltransferase (LCAT). Thenewly formed cholesterol esters are rapidly transferred from HDL to VLDL or IDL particlesby a cholesterol from transfer protein in plasma. The HDL promotes the removal ofcholesterol to as cholesterol transport. This transport is facilitates by the synthesis &secretion of apoprotein E by peripheral tissues. In addition to degradation by specification receptors, lipoproteins are also disposed ofby specific pathways, some of which operate in macrophages & other seavenger cells. Whenthe plasma concentration of a lipoprotein rises, the rate of its degradation by such pathwayincreases. This contributes to arterial walls (producing atheromas) & macrophages of tendons& skin (producing xanthomas). Recent evidences has implicated oxidized LDL as a major source of cholesterol inmacrophages within atheromas. Macrophages & endothelial cells possess few LDL receptors,but they do produces a “scavenger receptor” that recognizes LDL only after it’s lysinereduces have been chemically modified. When LDL is oxidation productes of fatty acids.This modifies particles taken up rapidly by macrophages through the scavenger receptor,such oxidation is likely to occur locally when LDL penetrates into arterial walls, & this eventmay be responsible for much of the deposition of cholesterol in the atherosclerotic plaques.Triglycerides Triglycerides are the form in which fats are chiefly occurs both in foodstuff & in thefat depots of most animals. They are valuable sources of energy storage & transport & are 44 Lipids

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