LIFESTYLE DISORDERS IN CHILDREN

1. 0

2. 1

3. 2

4. LIFE STYLE
• ROUTINE
• DRESS
• EAT
• EXERCISE/PHYSICAL ACTIVITY
• DRINK
• SMOKE
• TECHNOLOGY
• BELIEF
• ATTITUDE
3

5. ROUTINE
-SLEEPINESS
-STRESS
-ANXIETY
-DEPRESSION
4

6. DRESS
-POOR EXPOSURE TO SUNLIGHT
-MORE EXPOSURE TO VECTORS, ALLERGENS.
5

7. EAT
-OBESITY
-VITAMIN D DEFICIENCY
-VITAMIN B12 DEFICIENCY
-GASTRIC REFLUX
6

8. 7

9. OBESITY
• OBESITY-IS A CONDITION WHERE A PERSON HAS ACCUMULATED SO
MUCH BODY FAT THAT IT MIGHT HAVE A NEGATIVE EFFECT ON THEIR
HEALTH
• BODY FAT CONTENT -HIGH ADIPOSITY IN INFANCY
-LOWEST AT 5-6 YRS
-GRADUAL INCREASE TILL ADOLESCENCE.
• OBESITY > 2 YRS -BMI > 95TH PERCENTILE
• OVERWEIGHT -BMI 85TH- 95TH PERCENTILE
• BMI -WT IN KG/ HEIGHT IN M2
8

10. CUT OF VALUES OF BMI FOR
OVERWEIGHT
Agency Tendency for
overweight
State of overweight
WHO >25 kg/m2 >30 kg/m2
IOTF >23kg/m2 >25 kg/m2
INCHS >85th centile >95thcentile
9

11. OBESITY
• AMONG DELHI SCHOOL CHILDREN, 5% OBESITY
AND 17-19% OVERWEIGHT . SIMILAR FIGURES IN
REST OF INDIA ALSO
• PREVALENCE OF OBESITY AND OVERWEIGHT IS
HIGHER IN BOYS THAN IN GIRL
10

12. OBESITY CONTINUE………
ETIOLOGY
FACTORS RESPONSIBLE
- HEREDITARY
-ENVIRONMENTAL FACTORS
TYPES
-EXOGENOUS
-ENDOGENOUS
11

13. OBESITY CONTINUE..
• EXOGENOUS (95%)
-PHYSIOLOGICAL IN EARLY CHILDHOOD
- CONSTITUTIONAL OR FAMILIAL
-OVER EATING ( BEHAVIORAL)
- POOR PHYSICAL ACTIVITY
1) HABITUAL
2) PATHOLOGICAL: PHYSICAL HANDICAPS
12

14. OBESITY CONTINUES……..
• ENDOGENOUS(<5%)
ENDOCRINAL
-HYPOTHYROIDISM
-CUSHING SYNDROME
-PCOD
GENETICS
-LAURENCE –MOON-BIEDL SYDROME
-PRADER-WILLI SYNDROME
MONOGENETIC
-LEPTIN DEFICIENCY
13

15. OBESITY CONTINUES
HYPOTHALAMIC
-POST MENINGITIC/ENCEOPHALITIC SEQUELE
- FROHLICH SYNDROME
DRUGS
- STERIODS,VALPROATE,CLONAZAPAM
14

16. OBESITY CONTINUES….
COMPLICATIONS- MOST CASES OF CHILDHOOD OBESITY
ARE MERELY
OVERWEIGHT WITH RARE COMPLICATION
EXCEPT
PSYCHOLOGICAL CONCERN AND POOR
BODY
IMAGE.
EXTREME OBESITY HAS SIGNIFICANT MORBIDITY
BEHAVIORAL : - SOCIAL /PSYCHOLOGICAL STRESS 15

17. OBESITY CONTINUES….
SKELETAL : -GENU VALGUM, SLIPPED
FEMORAL
EPIPHYSIS.
RESPIRATORY - OBSTRUCTIVE SLEEP APNEA
SYNDROME
CARDIOVASCULAR -HYPERTENSION
METABOLIC -HPERLIPIDEMIA,DM
OBESITY IN LATER LIFE 16

18. OBESITY CONTINUES
RARE COMPLICATION OF OBESITY
PICKWICKEN SYNDROME
PERSISTANT RESPIRATORY DISTRESS WITH
HYPOXIA,CYANOSIS,POLYCYTHEMIA,
CARDIOMEGALTY AND CCF.
17

19. OBESITY CONTINUES….
PREVENTION OF OBESITY
-START IN EARLY CHILDHOOD
-HARDER TO TREAT IN ADULTS
18

20. OBESITY CONTINUES….
MANAGEMENT
• DIETARY CHANGES
- LOW CALORIE, LOW FAT
- NORMAL PROTEIN
- HIGH FIBRE
- AVOID JUNK FOOD AND CARBONATED
- DRINKS
WEIGHT REDUCTION 500GM/WEEK
19

21. OBESITY CONTINUES….
• ENCOUARGEMENT OF PHYSICAL ACTIVITY
-OUTDOOR GAMES AND SWIMMING
• TREATMENT .OF IDENTIFIABLE CAUSE.
• PSYCHOSOCIAL SUPPORT TO CHILD AND FAMILY
20

22. OBESITY CONTINUES….
• DRUGS
ORISTAT-(GASTRIC LIPASE INHIBITOR)
SIBUTRAMINE(NEUROTRANSMITTER MODULATOR)
LEPTIN (LEPTIN DEFICIENCY)
OCTEOTRIDE ( HYPOTHALAMIC OBESITY)
• SURGERY-GASTRIC BANDAGE OR JEJUNOILEAL BYPASS(
BMI>40)
21

23. LIFE STYLE CHANGES AND
OBESITY MANAGEMENT
• CHANGE IN SEDENTARY LIFE STYLE, DECREASE
CONSUMPTION OF CALORIE DENSE FOOD AND
INCREASE OUTDOOR ACTIVITY TEND TO
DECREASE THESE DISORDERS.
22

24. MESSAGE ABOUT EATING HABITS
• NUTRITIONAL DISEASES ARE CHANGING WITH CHANGING
LIFE STYLE
• TRADITIONAL BELIEF LARGE WEIGHT IS HEALTHY
….WRONG
• MANY ACUTE /CHRONIC/RECURRENT DISORDERS MAY
HAVE NUTRITIONAL BASIS
• KEEP AN EYE OPEN
23

25. COMPUTER VISION SYNDROME
• IT IS ALSO CALLED DIGITAL EYE STRAIN.
• IT IS A GROUP OF EYE AND VISION RELATED PROBLEMS
DUE TO PROLONGED USE OF COMPUTER , TABLET, CELL
PHONE USE.
• EYE DISCOMFORT AND VISION PROBLEMS- INCREASE
WITH AMOUNT OF DIGITAL SCREEN USE.
24

26. CVS CONTINUE……..
• SYMPTOMS-
- EYESTRAIN
-HEADACHE
-BLURRED VISION
-DRY EYES
-NECK AND SHOULDER PAIN
• AGGRAVATING FACTORS
-POOR LIGHTING
-GLARE AT SCREEN
-IMPROPER VIEWING DISTANCE 25

27. CVS CINTINUES…….
-POOR SITING POSTURE
- UNCORRECTED VISION PROBLEMS
26

28. CVS CONTINUES…….
• VISUAL SYMPTOMS DEPEND ON- LEVEL OF VISUAL ABILITY
-AMOUNT OF TIME SPENT ON
LOOKING DIGITAL SCREEN
• MANY OF VISUAL SYMPTOMS ARE TEMPORARY AND
DECLINE AFTER STOPPING COMPUTER WORK
• MANY PEOPLE MAY EXPERIENCE REDUCED VISUAL
ABILITY,BLURRED VISION EVEN AFTRE STOPPING WORK
ON COMPUTER
27

29. CVS CONTINUES…
• IF CAUSE OF PROBLEM NOT CORRECTED , WORSONS THE
FUTURE USE OF DIGITAL SCREEN
DIAGNOSIS-HISTORY
- VISION ACUITY MEASUREMENT
- REFRACTION
28

30. CVS CONTINUES……
MANAGEMENT
• EYE CARE - SPECIAL LENS DESIGN,LENS COATING.
- PROPER BODY POSITIONING
29

31. CVS CONTINUES…….
-ANTI GLARE SCREEN-USE SCREEN GLARE FILTER
• SEATING POSITION
-CHAIR SHOULD BE COMFORATABELY
PADDED HEIGHT SHOULD BE
ADJUSTED SO THAT
FEET SHOULD REST FLAT ON FLOOR
- IF CHAIR‘S ARMS SHOULD BE ADJUSTED
THAT IT SHOULD PROVIDE ARM SUPPORT WHILE TYPING
WRIST SHOULD NOT REST ON KEYBOARD.
30

32. CVS CONTINUES…….
LOCATION OF COMPUTER SCREEN
-15-20 DEGREE BELOW EYE LEVEL
-20-28 INCHES AWAY FROM EYES
REFERENCE MATERIAL
-ABOVE THE KEYBOARD AND BELOW THE MONITOR
-IF NOT POSSIBLE-DOCIUMENT HOLDER BESIDE THE
MONITOR
31

33. CVS CONTINUES
LIGHTENING
-AVOID GLARE FROM-OVERHEAD LIGHTING OR WINDOWS
USE DRAPES AT WINDOWS AND USE LOWER WATTAGE BULB IN DESK
LAMP
• REST BREAK-
-REST YOUR EYE FOR 15 MINUTE AFTER 2 HRS OF CONTINUOUS
COMPUTER USE.
• BLINKING
- BLINK FREQUENTLY TO MINIMIZE THE PROBLEM OF DRY EYE .
32

34. CVS CONTINUE……
33

35. VITAMIN D DEFICIENCY
• RICKETS- FAILURE OF MINERALISATION OF GROWING
BONES.
• RDA NEWBORN-400 IU/DAY
CHILDREN- 600IU/DAY
ADOLESCENTS 800IU
34

36. PHYSIOLOGY OF VITAMIN D
SKIN DIET
(7 DEHYDROCHOLESTEROL) D2&D3
UV LIGHT
VITAMIN D 3 (CHOLECALCIFEROL)
LIVER
25 (OH) D3
KIDNEY
1 HYDROXYLASE 24 HYDROXYLASE
1,25 (OH)2D3 24,25 (OH) D3
(ACTIVE) (INACTIVE FORM)
35

37. PATHOPHYSIOLOGY
VITAMIN D DEFICIENCY
REDUCED CA AND P ABSORPTION FROM GUT AND KIDNEYS
RISE IN PARATHORMONE
CALCIUM MOBILISATION FROM BONES AND RESORPTION FROM KIDNEYS
DEFICENT MINERALISATIION
INCREASED OSTEOBLASTIC ACTIVITY WITH ELEVATED LEVEL
OF ALKALINE PHOSPHATASES -!ST MARKER
INCREASED RENAL ABSORPTION PF CALCIUM
PHOSPHORUS EXCRETION AND LOW LEVEL OF P -2ND MARKER
36

38. ETIOLOGICAL CLASSIFICATION OF
RICKETS
1) VIT D DEFICIENCY (NUTRITIONAL RICKETS)
-HIGHER REQUIREMENT
-INADEQUATE DIETARY INTAKE
-LACK OF SUN EXPOSURE
-POOR STORES AT BIRTH
-MALABSORPTION STATES
-ANTICONVULSANT THERAPY
37

39. CLASSIFICATION OF RICKETS
2)VITAMIN D RESISTANT (REFRACTORY RICKETS)
CHRONIC HEPATIC DISEASE
CHRONIC RENAL DISEASE
HYPOPHOSPHATEMIC RICKETS
RENAL TUBULAR ACIDOSIS OR FANCONI DISEASE
3)VITAMIN D DEPENDENT RICKETS
TYPE 1-AUTOSOMAL 1-HYDROXYLASE DEFICIENCY
TYPE 2-END ORGAN RESISTANCE TO VITAMIN D
38

40. RICKETS
39

41. CLINICAL MANIFESTATION
6 MONTHS – 2 YRS
CHANGES
CRANIOFACIAL
• CRANIOTABES-SOFTENING AND THINNING
IF SKULL BONES PING PONG LIKE APPEARANCE.
• FRONTAL BOSSING.
40

42. CLINICAL MANIFESTATION
• CAPUT QUARDRATUM—BOX HEAD OR HOT COSS BUN LIKE
DUE TO FRONTOPARIETAL BOSSING
• DELAYED DENTITION
• DELAYD CLOSURE OF ANTERIOR FONTANEL.
41

43. CLINICAL MANIFESTATION
THORACIC CHANGES-
• RICKETIC ROSARY-WIDENING OF
COSTOCHONDROL JUNCTION
• STERNAL DEFORMITIES
PECTUS EXCAVATUM
PECTUS CARNIATUM
42

44. CLINICAL MANIFESTATION
HARRISON SULCUS-GROOVE ALONG LOWER COSTAL MARGIN
LIMB DEFORMITIES
• WIDENING OF WRIST/ANKLES
43

45. CLINICAL MANIFESTATIONS
• ABNORMAILITIES IN LOWER LIMBS
-KNOCK KNEE
-BOW LEGS
44

46. CLINICAL MANIFESTATIONS
SPINAL DEFORMITIES
• KYPHOSIS
• SHORT STATURE-SPINAL DEFORMITIES
GENERALIZED HYPOTONIA
• POT BELLY
• VISCREOPTOSIS
• OTHER MANIFESTATIONS
–RECURRENT RESPIRATORY INFECTIONS
45

47. DIAGNOSIS
SYMPTOMS
RADIOLOGICAL CHANGES
• WIDENING OF EPIPHYSIAL PLATES
• FRAYING
• CUPPING
• SPLAYING
46

48. DIAGNOSIS
BIOCHEMICAL CHANGES
• ELEVATED S.ALKALINE PHOSPHTASES LEVEL->20 KA
UNITS
• LOW S.PHOSPHORUS LEVEL
• SERUM VITAMIN D LEVELS- <5 NG/ML
47

49. TREATMENT OF RICKETS
• STROSS REGIMEN
-SINGLE DOSE OF ORAL OR IM 300000-600000 IU ALONG
WITH ORAL CALCIUM
• OR 60000 IU× 10 DAYS.
• OR 2000-6000 IU/DAY
• REPEAT X RAY AFTER 2-3 WEEKS
• ABSENCE OF LINE OF PREPRATORY CALCIFICATION-REPEAT SAME DOSE
• REPEAT X-RAY AFTR 4-6 WEEKS –NO IMPROVEMENT
INVESTIGATE FOR OTHER CAUSES.
48

50. PREVENTION
• ADEQUATE EXPOSURE TO SUNLIGHT
• VITAMIN D SUPPLEMENTATION (400IU/DAY) IN PRETERM
AND RAPIDLY GROWING CHILDREN
49

51. MEGALOBLASTIC ANAEMIA
• ANAEMIA WITH PRESENCE OF CHARACTERISTICS MEGALOBLASTS IN
PERIPHERAL SMEAR.
• COMMONLY DUE TO DEFICIENCY OF –VITAMIN B12 , FOLIC ACID
• VITAMIN B12 –PRESENT IN ANIMAL SOURCES
ABSENT IN PLANT SOURCES
SYNTHESIZED BY COLONIC BACTERIA
• RDA-0.5-1.5 MG/DAY
• ETIOLOGY-RARELY DIETARY
USUALLY DUE TO CONGENITAL/ACQUIRED DEFECT IN
ABSORPTION
50

52. COMMON MANIFESTATION OF B 12
• MACROCYTIC ANAEMIA
• GLOSSITIS
• NONSPECIFIC GASTROINTESTINAL
SYMPTOMS(ANOREXIA,NAUSEA,VOMITING.
• NEUROLOGIC SYMPTOMS
(DEMENTIA,DEPRESSION,PSYCHOSIS)
• SKIN HYPERPIGMENTAION -KNUCKLES AND
THIGHS.
51

53. DIAGNOSIS
• MEGALOBLASTIC ANAEMIA THAT DOES NOT RESPOND TO
FOLIC ACID THEREPY
• LOW SERUM VITAMIN B12 LEVELS(<100 PG/DL)
• METHYLMALONIC ACIDUREA
• SHILING TEST
52

54. MANAGEMENT
• ORAL THEREPY USELESS-DEFECTIVE ABSORPTION
• CASES WITHOUT NEUROLOGICAL SIGNS-LIFE LONG
MONTHLY THERAPY WITH IM VITAMIN (1MG)
• CASES WITH NEUROLOGICAL SIGNS-DAILY THERAPY X 2
WEEKS,FOLLOWED BY LIFE LONG MONTHLY THERAPY
53

55. SUBSTANCE ABUSE
• TOBACCO AND ALCOHOL USE STARTS DURING
ADOLESCENCE.
• ALCOHOL(21%), TOBACCO(14%), CANNABIS(3%), AND OPIUM
(0.4%) ARE THE MOST PREVALENT SUBSTANCE ABUSE IN
INDIAN ADOLESCENCE.
• ADDICTS ARE MORE PRONE TO ACCIDENTS, INJURIES,
VIOLENCE, TRADING SEX FOR DRUGS, HIV, HEPATITIS C,
SEXUALLY TRANSMITTED DISEASE AND TUBERCULOSIS.
54

56. DEPRESSION
• DEPRESSION IS THE TOP CAUSE OF ILLNESS AND
DISABILITY AMONG ADOLESCENTS AND SUICIDE IS
THE THIRD CAUSE OF DEATH.
• COMPLETED SUICIDES ARE HIGHER IN BOYS
• ATTEMPTED SUICIDES ARE HIGHER IN GIRLS
55

57. SOCIAL CHALLENGES
• MEDIA
• WITH THE AVAILABILITY OF ELECTRONIC MEDIA, CHILDREN
ARE EXPOSED TO INFORMATION FROM ALL ACROSS THE
WORLD.
• THIS EXPOSURE IS UNSUPERVISED BECAUSE OF WORKING
PARENTS AND INCREASING USE OF ELECTRONIC GADGETS.
• DUE TO INABILITY TO SEPARATE FACT FROM FANTASY,
CHILDREN MAINLY ADOLESCENTS SUCCUMB TO THE
GLAMOROUS PORTRAYAL OF TOBACCO OR ALCOHOL
CONSUMPTION, UNREALISTIC EXPECTATIONS, PHYSICAL
AGGRESSION, DESTRUCTIVE BEHAVIOR AND UNPROTECTED
SEX.
56

58. MENTAL HEALTH PROBLEMS
CONT…)
SLEEP DISTURBANCE
• DURING THE PERIOD OF RAPID GROWTH,
ADOLESCENTS HAVE INCREASED SLEEP
REQUIREMENT.
• INADEQUATE SLEEP MAY CAUSE POOR SCHOOL
PERFORMANCE , DAYTIME DROWSINESS,
AGGRESSIVE BEHAVIOR, CONDUCT DISORDER,
ANXIETY, RESTLESS LEG SYNDROME AND
DEPRESSION.
57

59. MENTAL HEALTH PROBLEMS
CONT…)
• INADEQUATE SLEEP MAY CAUSE POOR SCHOOL
PERFORMANCE , DAYTIME DROWSINESS,
AGGRESSIVE BEHAVIOR, CONDUCT DISORDER,
ANXIETY, RESTLESS LEG SYNDROME AND
DEPRESSION.
• SLEEP DEPRIVED TEENS MAY HAVE PERIODS OF
SUBCONSCIOUS BOUTS OF SLEEP DURING THE
DAYTIME, MAKING THEM PRONE TO INJURIES AND
ACCIDENTS.
58

60. LIFE STYLE DISEASE
PREVENTION PROGRAMS
• FIVE YEAR PROGRAM ADVOCACY AND AWARENESS
• STANDARD SET OF SLIDES AND TRAINING MODULES FOR
PAEDIATRICIANS
• SCHOOL TEACHERS AND PARENTS
• PRE AND POST ASSESSMENT OF THE INTERVENTION
STRATEGIES
59

61. KEY MESSAGE
• INDIA : ALARMING EPIDEMICS OF T2 DM,CHD AND OTHER
LSD
• THE FOAD EPIDEMICS IS POTENTIALLY PREVENTABLE
WITH LIFE STYLE CHANGES IN CHILDHOOD AND
ADOLESCENCE
• TARGETED EFFECTIVELY THROUGH SCHOOL/COLLEGE
CAMPAIGNS TO FOCUS IN HEALTHY EATING, INCREASED
PHYSICAL ACTIVITY AND REDUCTION IN SEDENTARY
HABITS
60

62. AVAYAMA
DIVA
SWAPNA
SLESHMALA
AHARA
SEVINA
ADHYASHA-
NA
61

63. Nidana
sevana
Kapha
sanchaya
Anganam
gaurava,Aalsya
62

64. Further indulgence in Kaphakara
ahara-vihara
Aggravation of Kapha dosha along with
production of aama anna rasa
Kapha dosha vriddhi 63

65. Due to nidana sevana
श्लेष्म प्रकोप
Vriddhi of medho dhatu,sanga in
medhovaha srotas
Vata prakopa and inturn jataragni
sandookshana
Atibhubhukshana inturn
medho datu vriddhi
64

66. • DOSHA DUSHYA SAMURCHANA TAKES PLACE AT THIS STAGE.
• KAPHA SAMURCHANA TAKES PLACE WITH MEDO DHATU.
LEADING TO PRODROMAL SYMPTOMS SUCH AS
• GURU GHATRATVA
• SWEDAAABHADA
• ASAHASATVA
• TEEKSHNAGNI –KSHUDATI MATRA-PIPPASATIYOGA.
65

67. LEADING TO SYMPTOMS SUCH AS
• MEDO-MAMSA VRIDDHI
• CHALA SPHIK-UDARA-STANA
• AYATOPA CHAYOTSAHA
66

68. मेदोमाांसातिवॄद्धत्वाश्चलतफिगुदरफिनः।
अयथोपचयोत्साहो नरो अतिफथूल उच्यिे ॥ (CHA.SU.21/9)
• MEDO-MAMSA VRIDDHI
• CHALA SPHIK-UDARA-STANA
• AYATOPA CHAYOTSAHA

69. अतिस्थूलस्य िावदायुषो ह्रासो जवोपरोधः कॄ च्छ्रव्यवायिा दौर्बल्यं दौर्बन्ध्यं
स्वेदार्ाधः क्षुदतिमात्रं पपपासातियोर्श्चेति भवन्ध्यष्टौ दोषाः ॥
(CH.SU.21/4)
• आयुषो ह्रास- DUE TO LACK OF POSHANA OF OTHER
DHATUS OTHER THAN MEDO DHATU.

70. • जवोपरोध -DUE TO SHARIRA SHAITILYA AND
SUKUMARATHA STHULA PERSONS ARE UTSAHA
RAHITA.
• कॄ च्छ्रव्यवायत -DUE TO SHUKRA ALPATA AND AVRUTA
OF SHUKRA MARGA BY MEDO DHATU.
• दौर्बल्य - DUE TO VISHAMA DHATU VRIDDI.

71. • दौर्बन्ध्य - DUE TO ADIKA MEDA.
(DOURGANDHYA IN SWEDA)
• स्वेदार्ाध -DUE TO MEDA SWABHAVA.
• क्षुदततमात्रं - DUE TO TEEKSHA AGNI AND VAYU.
• पपपासाततयोर् - VAYU BAHULYATA IN KOSTA.

72. UPADRAVAS IN STHOULYA

73. Visar
pa
Kushta
Bhaga
n-
dara
Jwara
Prame
-ha
Atisara
Arsha
Sleepa
d-a
KamalaApachi

75. • IT IS EASY TO PLUCK A PLANT WHEN IT IS
STILL A SAPLING, BUT IT IS DIFFICULT WHEN
IT BECOMES A TREE.
• IF SOME ATTENTION IS PAID TOWARDS THE
LIFESTYLE SEVERAL DISEASE CAN BE
PREVENTED SUCCESSFULLY..

77. • तदततस्थौल्यमततसम्पूरणाद्र्ुरुमधुरशीतस्स्िग्धोपयोर्ादव्यायामादव्यवाया
द्ददवास्वप्िाद्धषबतित्यत्वाद- चिन्धतिाद्र्ीजस्वभावाच्छ्िोपजायते|
76

78. • आहारश्ि पवहारश्ि यः स्याद्दोषर्ुणः समः|
• धातुभभपवबर्ुणश्िापप स्रोतसां स प्रदूषकः||२३||
77

79. • अततस्थूलस्य तावदायुषो ह्रासो जवोपरोधः [१] कृ च्छ्रव्यवायता दौर्बल्यं
दौर्बन्ध्यं स्वेदार्ाधः क्षुदततमात्रं पपपासाततयोर्श्िेतत भवन्धत्यष्टौ दोषाः|
78

80. • मेदोमांसाततवृद्धत्वाच्छ्िलस्स्िर्ुदरस्तिः|
• अयथोपियोत्साहो [२] िरोऽततस्थूल उच्छ्यते||९||
79

81. • क्षुस्त्पपासातपसहः शीतव्यायामसंसहः|
• समपक्ता समजरः सममांसियो मतः||१९||
80

82. • र्ुरु िातपबणं िेष्टं स्थूलािां कशबिं प्रतत|
• कृ शािां र्ृंहणाथं ि लघु सन्धतपबणं ि यत्||२०||
81

83. 82