DEPARTMENT OF POST GRADUATE STUDIES IN SWASTHAVRITTA SHRI DHARMASTHALA MANJUNATHESHWARA COLLEGE OF AYURVEDA & HOSPITAL HASSAN - 573 201. Certificate This is to certify that the thesis entitled “EFFECT OF UDVARTHANA IN STHOULYA” is the record of research work conducted by ‘PRASANNA KUMAR K’ under my direct supervision and guidance as a partial fulfillment for the award of the degree of M.D.(Ayu) in Swasthavritta. Some of the observations made in this elaborative clinical study are original and have definitely contributed in the advancement of the existing knowledge of the subject. The candidate has fulfilled all the requirement of ordinances laid down in the prospectus of Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka for the award of Degree of Doctor of Medicine (Ayu.) Swasthavritta. I am fully satisfied with his work and recommend this thesis to be submitted for adjudication. Guide HOD Date: 28-03-04 Place: HASSAN Dr. Sajitha.K M.D.(Ay) Asst. Prof. Dept. of PG studies in Swasthavritta SDM College of Ayurveda & Hospital HASSAN. Prof. Ramana. G.V M.D (Ay) Prof. & HOD Dept. of PG studies in Swasthavritta SDM College of Ayurveda & Hospital HASSAN.
EFFECT OF UDVARTHANA IN STHOULYA” ‘PRASANNA KUMAR K’ DEPARTMENT OF POST GRADUATE STUDIES IN SWASTHAVRITHA S.D.M. COLLEGE OF AYURVEDA AND HOSPITAL,HASSAN
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DEPARTMENT OF POST GRADUATE STUDIES IN SWASTHAVRITTA
SHRI DHARMASTHALA MANJUNATHESHWARA
COLLEGE OF AYURVEDA & HOSPITAL
HASSAN - 573 201.
Certificate
This is to certify that the thesis entitled “EFFECT OF
UDVARTHANA IN STHOULYA” is the record of research work
conducted by ‘PRASANNA KUMAR K’ under my direct supervision and
guidance as a partial fulfillment for the award of the degree of M.D.(Ayu)
in Swasthavritta.
Some of the observations made in this elaborative clinical
study are original and have definitely contributed in the advancement of the
existing knowledge of the subject.
The candidate has fulfilled all the requirement of ordinances
laid down in the prospectus of Rajiv Gandhi University of Health Sciences,
Bangalore, Karnataka for the award of Degree of Doctor of Medicine
(Ayu.) Swasthavritta.
I am fully satisfied with his work and recommend this thesis to
be submitted for adjudication.
Guide HOD
.
Date: 28-03-04
Place: HASSAN
Dr. Sajitha.K M.D.(Ay)
Asst. Prof.
Dept. of PG studies in Swasthavritta
SDM College of Ayurveda & Hospital HASSAN.
Prof. Ramana. G.V M.D (Ay)
Prof. & HOD Dept. of PG studies in Swasthavritta
SDM College of Ayurveda & Hospital
HASSAN.
Ayurmitra
TAyComprehended
CONTENTS
I. Introduction 1-4
II. Literary review
1. Sthoulya 5-32
a. Paribhasha 6
b. Historical Background 7-9
c. Physiological consideration of Meda Dhatu 10-11
d. Nidana 12-16
e. Samprapthi 17-21
f. Poorvaroopa 22
g. Roopa 23-25
h. Upadrava 26-27
i. Sadhyasadhyata 28
j. Chikitsa 29-33
2. Obesity
a. Lipids 34-41
b. Definition 42-43
c. Etio-Pathogenesis 44-50
d. Assessment 51-54
e. Morbidity- Mortality 55
f. Complication 55
g. Treatment 56-59
3. Udvartana
h. Paribhasha 60
i. Concept of Rookshana 61-63
j. Historical Background 64
k. Classification 65
l. Benefits 66
m. Procedure and mode of Action (rubbing) 67-70
III. Clinical study
a. Study design 71
b. Reason for selecting Study Design 72
c. Objectives of Study 74
d. Selection criteria 74
e. Objective Parameters 75
f. Subjective Parameters 75-78
g. Drug Review 79-80
i. Treatment Procedure 81-82
IV. Observation and Results 83-109 V. Discussion 110-124
VI. Summary and Conclusion 125-129
VII. List of Reference 130-131
VIII. Bibliography 132-133
IX. Annexure I-XIV
Acknowledgement
Effect of Udvarthana in Sthoulya
Acknowledgement
I offer my prayers to Lord Aanjaneya and Sri Raghavendra Swamiji
who gave me strength to overcome all the difficulties during this Thesis work.
I bow my head on the foot of Dr. Virendra Hegdeji, the founder
president of SDMCA, Hassan for his endless service to society.
I am very much thankful to Prof. Prasanna .N. Rao, Principal, who
provided the necessary facilities for the completion of this work.
I express my sincere gratitude to most honourable and esteemed teachers
Dr. Ramana.G.V, HOD and Dr. Sajitha .K, Guide, for their unforgettable
parental affection and patience cooperation to give suggestions at every step in
accomplishing the present work.
My most respects and indebtedness to Dr. Sekhar, Dr. Bhaskar Rao,
Dr. Mallika, Dr. Muralidhar Pujar, Dr. Prasanna Kerur, Dr. Sanjay Das
and Statistician Dr. Mahadevappa for their valuable suggestions.
I take this opportunity to thank Prof. B.G. Gopinath, Dr. B. Srinivas
Prasad, Dr.Chandrashekar, Dr. Prakash Mangalasseri Dr. kishore
Patwardan and Dr. Kiran Gowda who taught me the science and arts of
medicine.
My vocabulary falls short of suitable words to express my deep sense of
gratitude to my friends Dr. Sairam, Dr. Krishna, Dr. Sudheer and Dr. Suhas
for their timely support and brotherly care.
I am greatfull to Dr. Manjunath N.S, Dr. Guruprasad. K and
Dr.Vijaya Lakshmi for their constant help.
It is a privilege for me to express my thanks to Dr.Srinibash Sahoo,
Dr.Gopikrishna, Dr.Dheeraj, , Dr.VishalAgarwal, and Dr.Manjunath NP.
I express my best wishes to Dr. Sudheendra, Dr. Shivakumar,
Dr.Guhesh, Dr. Monilal, Dr. Srikanth, Dr. Adithi, Dr. Manish and Dr.Uday.
Acknowledgement
Effect of Udvarthana in Sthoulya
I am thankful to internees Raghavendra, Poornima, Sudarani,
Shivananda, Nalina and Usha who helped me for survey work.
It was not possible to complete this work without Patients therefore I am
very much greatfull to each and every patient who cooperated me for this work.
I fail in my duty if I don’t recall Dr. Srikanth PL, Dr. Madhav Diggavi,
Dr. Srinivas T, Dr. Vishala, Dr. Anupama, Dr. Gurubasavaraj and Shobha
for their inspiration to join MD.
I take this opportunity to thank whole heartedly to Mr.
Raghavendrachar.B and Mr.Ramachandra who helped me for getting MD
seat.
This work has not been completed if Mr. Venugopal K and
Mr.Venugopalachar had not supported and blessed me. I am greatfull to Smt.
Shantha bai- my grand maa, Smt.Shashikala, Sri.Muralidhar Rao,
Smt.Chayya Kulkarni, Smt.Sudha shyati and Sri Eranna Pathrimath for
their encouragement and blessings.
This world of words failed to provide me a word just capable of
expressing my feelings to my friend late Preethi for her long-lasting inspiration.
I heartly acknowledge my love and affection to my brother Praveen,
sisters Poornima and Pallavi, Mr. Satish and my sweet Shreya.
On this occasion with a great reverence I humbly offer my pranamas at
the lotus feet of my mother Smt. Rekha Kulkarni and father Sri. K. Satya
Prakash, who have shaped me into what I am today. All the credit of this work
goes to them.
May Lord Dhanwanthri bless all with Hitayu and Sukhayu who helped
me directly and indirectly in completing this work.
Prasanna Kumar K
Effect of Udvarthana in Sthoulya
List of Tables
Table no.
Content Page no.
1 Paryaya of Sthoulya 06 2 Direct Aharatmaka Nidana 14 3 Indirect Aharatmaka Nidana 15 4 Viharatmaka Nidana 15 5 Manasika Nidana 15 6 Anya Nidana 16 7 Important Nidana with its features 16 8 Sthoulya Lakshana 25 9 Sthoulya Upadrava 27 10 Ahararupi Pathya – Apathya 32 11 Vihararupi Pathya – Apathya 33 12 Different constituents of lipoprotein 36 13 Normal limits of blood cholesterol 39 14 Distribution of adipose tissue. 40 15 Role of different genes 46 16 Interpretation of BMI 52 17 Drugs, there mode of action and adverse effects 58 18 Difference between Langhana and Rookshana 60 19 Effects of Rookshana karma: 61 20 Samyak Rookshana Lakshana 61 21 Rookshana athi yoga lakshana 61 22 Rookshana Ayoga Lakshana 63 23 Benefits of Udvarthana 66 24 Sthoulya cases as per Age-wise Distribution 83 25 Sthoulya cases as per Sex wise distribution 83 26 Sthoulya cases according to their Religion 84 27 Sthoulya cases according to their Socio-economical status 84 28 Sthoulya cases according to their occupation 84 29 Sthoulya cases according to their Prakruthi 84 30 Sthoulya cases according to chronicity of disease 85 31 Sthoulya cases according to Family history 85 32 Sthoulya cases according to quantity of food consumption 85 33 Sthoulya cases according to frequency of food consumption 86 34 Sthoulya cases according to their Pana 86 35 Sthoulya cases according to Rasa preferred 86 36 Sthoulya cases according to Nidra kala 86 37 Sthoulya cases according to their Adhyatana Agni 87 38 Sthoulya cases according to their Poorvagni 87 39 Sthoulya cases according to their Abhyahvarana shakthi 87 40 Sthoulya cases according to their Jarana shakthi 87 41 Sthoulya cases according to their Jatha Desha 88 42 Sthoulya cases according to their Samvrudha Desha 88 43 Sthoulya cases according to their Vyadhitha Desha 88
Effect of Udvarthana in Sthoulya
Cont…
Table no. Content Page no. 44 Sthoulya cases- Body frame 89 45 Sthoulya cases- Educational status 89 46 Sthoulya cases as their per Associated Features 89 47 Sthoulya cases as per their Vihara 90 48 Changes in chala spik, sthana and udara lambana 90 49 Changes Ayathaupachaya utsaha hani 90 50 Changes in Swedadhikyata 91 51 Changes in Ayase Swasa 91 52 Changes in Nidradhikya 91 53 Changes in Adhika Kshuda 92 54 Changes in Ahara matra 92 55 Changes in Ahara kala 92 56 Changes in Athi Pipasa 93 57 Changes in Kshuda sahatva 93 58 Changes in kshuda souhitya 93 59 Changes in Alpa vyayama 94 60 Changes in Anga gourava 94 61 Changes in Anga sithilatha 94 62 Changes in Gatra sada 95 63 Statistical analysis of Subjective assessment 95 64 Changes in weight 97 65 Response in weight 97 66 Changes in BMI 98 67 Response in BMI 98 68 Statistical analysis of changes in weight and BMI 99 69 Response in chest circumference 100 70 Response in abdomen circumference 100 71 Response in hip circumference 100 72 Response in Mid-arm circumference 101 73 Response in Mid-thigh circumference 101 74 Statistical analysis of Circumference of Chest,
Abdomen, Hip, Mid-arm, Mid-thigh 102
75 Decrease in Total cholesterol level 102 76 Changes in Total cholesterol 103 77 Changes in HDL 103 78 Increase of HDL level 104 79 Changes in LDL 104 80 Decrease of LDL level 105 81 Changes in Triglycerides 105 82 Decrease of Triglycerides level 106 83 Statistical analysis lipid profile 106
Effect of Udvarthana in Sthoulya
Contd..
Table no.
Content Page no.
84 Age wise distribution of survey patients 107 85 Sex wise distribution of survey patients 107 86 Religion wise distribution of survey patients 107 87 Nature of work wise distribution of survey patients 108 88 Diet wise distribution of survey patients 108 89 Height wise distribution of survey patients 108 90 Weight wise distribution of survey patients 109 91 B.M.I wise distribution of survey patients 109 92 Synonym of Sthoulya with modern interpretation 110 93 Common Indian preparation with kcal.of energy IX 94 Activities and caloric burn for different weight X 95 Recommended energy intake for age, height, & weight X 96 Height and weight for women of different ages XI 97 Height and weight for men of different ages XI 98 Common Indian cereals with their nutritive value XII 99 Common Indian vegetables with nutritive value XII 100 Miscellaneous Indian foodstuff with nutritive value XIII 101 Reducing and weight maintenance diet of high cost XIII 102 Reducing & weight maintenance diet of medium cost XIV 103 Reducing and weight maintenance diet of low cost XIV
Abbreviations
Effect of Udvarthana in Sthoulya
Abbreviations
(1) Cha. sam - Charaka samhita
(2) Su. sam - Sushruta samhita
(3) As. San - Astanga sangraha
(4) As.Hr. - Astanga hridayam
(5) Sha. sam. - Sharangadhara samhita
(6) Bh.Pr. - Bhava Prakasha
(7) Ma.Ni. - Madava Nidana
(8) Yo.Ra. - Yogarathnakara
(9) Ka. san - Kashapa samhita
(10) Ra. vai - Rasa vaisheshika
(11) su - Sutrasthana
(12) vi. - Vimanasthana
(13) sha - Shareera
(14) ni - Nidanasthana
(15) si. - Siddisthana sthana
(16) chi. - Chikitsasthana
(17) khila - Khilasthana
(18) Ut. - Uttarasthana
(19) BT - Before treatment
(20) AT - After treatment
(21) Dif. - Difference
Introduction
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1
Scientific and technological progress has made man highly sensitive and
critical; there by giving rise to different types of health problems. The
advancement of industrialization and communication is contributing towards
sedentary life styles, in turn causing chronic non- communicable diseases like
releasing hormone and particularly neuropeptide Y) have a role in the central
control of satiation.
c). Thermogenesis:
Brown adipose tissue in animals8, when stimulated by cold or food,
dissipates in the form of heat the energy derived from ingested food. This can be
a major component of overall energy balance and it has been suggested that this
may also apply to humans.
A β3-Adrenergic receptors6 are the principle receptors mediating
catecholamine- stimulated lipolysis in brown and white fat tissue. After a meal
or exposure to cold, relatively high concentrations of noradrenalin are released,
stimulating the low-affinity receptors in brown adipose tissue. Low β3-
Adrenergic receptor activity would decrease Thermogenesis and this can explain
why most obese patients require a very low calorie intake to maintain any weight
loss, and gain weight easily after only small calorie increases. Decreased
function of the receptors in white adipose tissues could slow lipolysis-causing
retention of lipid in fat cells. As β3-Adrenergic receptors are more frequent in
visceral adipose tissues, this would explain the regional distribution of fat in
obese subjects.
☻Occupation:
Obesity is seen more in the people associated with sedentary life style
occupations such as clerks, managers, housewives etc.
☻ Life style factors -Physical activity:
Obesity is rarely seen among persons who lead active lives. It is very
common in those who lead sedentary lives. With extensive use of transport
facilities and mechanization of industry, the proportion of people who take
adequate exercise has decline and the number of persons leading sedentary lives
has been increasing. Obese patients tend to expend more energy during physical
activity as they have a larger mass to move. On the other hand, many obese
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49
patients decrease their amount of physical activity. The energy expended on
walking at three miles per hour is only 3.7 kcal/min and therefore increase in
xercise plays only a small part in loosing weight. Uses of alcohol frequently will
cause deposition of adipose as one gram of alcohol gives 7 kcal of energy.
☻ Drugs:
Some of the drugs like Corticosteroids; Sulphonilureas etc. will cause
obesity in long-term use. The drugs, which are used to treat psychological
diseases like Carbamazepine, Phenobarbitone plays a key role in the
manifestation of the disease- obesity.
3. Environmental factors:
This is an extrinsic factor that includes all that which is external to the
individual human host, living and non-living and with which he is in constant
interaction. This factor is again divided into:
Physical environment:
This includes air, water and food. In Obesity only food factor is
applicable which is already discussed.
Biological environment:
It includes universe of living things, which surrounds man like microbes,
insects, animals and plants. All theses may not be applicable for Obesity.
Psycho-social environment:
It covers a complex of Psychosocial factors which are defined as “those
factors affecting personal health, health care and community well being”. These
are cultural valves, customs, habits, beliefs, attitudes, morals, religion,
education, lifestyles, social and political organization.
During some of the religious fests, sweets and oily rich recipes will
provide additional calories to man and will make him to suffer from Obesity in
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50
future. The country like India is rich in many customs and religious festivals and
people of this country are more prone to get this disease when compared with
other countries.
Types of obesity
In simple the Obesity can be classified as:
1. Exogenous obesity: A common form due to excessive intake of food. The
distribution of fat is uniform, although somewhat excessive under the chin
(double chin) and the abdomen. This is also termed as simple obesity or
primary Obesity.
2. Endogenous or glandular obesity: when being overweight is the primary
complaint, an endocrine disorder is seldom the cause. This is also known as
secondary Obesity9.
Obesity may be mild, moderate or severe, or as described by one author,
“enviable”, “regal” or “pitiable”.
The manner of distribution of fat may be of some diagnostic value.
Distribution of fat:
1) Generalized type usually seen in alimentary or exogenous type.
2) Central or trunk type, involving only the trunk and neck. Ex: Cushing’s
syndrome and Hypothyroidism.
3) Superior or buffalo type, involving the face, neck, arms and upper part of
trunk. Ex Cushing’s syndrome and Hypothyroidism.
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4) Inferior type, involving the lower part of trunk and legs (called
lipodystrophia when accompanied by wasting of upper half of the body)
5) Girdle type, involving the hips, buttocks, abdomen and with a “fatty
apron”, seen in pituitary or hypothalamic disorders.
6) Breeches or Trochanteric type, involving only the buttocks, as in the
“Hottentots negro”, seen in Hypogonadal obesity.
7) Lipomatous type or multiple lipomataosis, with localized deposits of fat
over the body (called Dercum’s disease or adiposis dolorosa when
associated with tenderness and pain over the fatty lumps).
Assessment of obesity
For the assessment of Obesity many formulations had been put forward.
The following are different methods to assess the obesity in terms of weight and
fat.
1. Body weight:
It is not an accurate measure to calculate excess fat, but is widely used
index. In epidemiological studies it is conventional to accept +2 S.D (standard
deviation) from the median weight for height as a cut-off point for obesity.
For adults, various other indicators are mentioned as follows:
a.) Body Mass Index (Quetelet’s Index):
= Weight in Kg / height in meter square. (Kg / m2)
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Table no. 16 showing the interpretation of BMI4:
SL. NO.
BMI STAGE COMMENTS
1 < 16.00 Grade III thinness High mortality 2 16.0-16.99 Grade II thinness High mortality 3 17.0-18.49 Grade I thinness Moderate mortality 4 18.5-24.99 Normal range Healthy 5 25.0-29.99 Grade I obesity Moderate mortality 6 30.0-39.99 Grade II obesity High mortality 7 > 40 Grade III obesity High mortality
b). Ponderal index10:
= Height in centimeters / cube root of body weight i.e. cms / kg1/3
c.) Broca index:
= Height in centimeters minus hundred (i.e. cms-100)
d.) Lorentz’s formula:
= Height in centimeters – 100 - height in centimeters – 150
Divided by 2 for women and 4 for men.
For women: Cms-100- Cms-150
2
For men: Cms-100- Cms-150
4
e.) Corpulence index:
= Actual weight divided by desirable weight.
This should not exceed 1.2
The B.M.I and the Broca index are widely used. A recent
FAO/WHO/UNO reports gives the much needed reference tables for B.M.I,
which can be used internationally as reference standards for assessing the
prevalence of obesity in a community. BMI is better index of obesity compared
with percent weight chart because it obviates the need for weight-height chart
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53
and unlike the later, is not affected by type of body built like light, medium and
heavy.
2. Skin Fold Thickness (SFT):
A large proportion of total body fat is located just under the skin. Since it
is most accessible, by measuring skin fold thickness obesity can be measured. It
is a rapid and “non-invasive” method for assessing body fat. Several varieties of
calipers like Harpenden skin calipers are available. But considering its cost,
Vernier calipers are used compromising for slight variation. The measurements
are taken at following sites11:
a. Mid triceps
b. Biceps
c. Sub scapular and
d. Suprailiac region.
The sum of the measurements should be less than 40 millimeters in boys
and 50 millimeters in girls or Triceps SFT alone is considered for assessment
and >18 and >32 mm in men and women respectively denotes obesity. Recent
evidence indicates that SFT used in west is not applicable in India.
Unfortunately standards for subcutaneous fat do not exist for comparison. More
over in extreme obesity measurement may not be possible and main draw back is
its poor repeatability.
3. Waist – hip ratio (WHR):
This is the waist circumference in centimeters divided by the hip
circumference in centimeters. The waist circumference is usually measured
halfway between the superior iliac crest and the rib cage in the mid-axillary line.
Where as the hip circumference is measured one-third of the distance between
the superior iliac spine and the patella.
WHR in central distribution of body fats i.e. a waist hip circumference
ratio of more than 1 in men and more than 0.9 in women is associated with a
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higher risk of morbidity and mortality than is a more peripheral distribution of
body fat i.e. WHR less than 0.85 in men and less than 0.75 in women.
The ratio of waist circumference to height or measuring the sagittal
diameter of the abdomen at the level of L4 / L5, provides a useful index of intra-
abdominal fat content. The diseases associated with abdominal obesity include
hypertension, Hyperlipidemia, insulin resistance, diabetes mellitus and cardio-
vascular diseases
4. Others:
In addition to above, three well established and more accurate
measurement is used for estimation of body fat. They are measurement of total
body water, measurement of total body potassium, measurement of body density
and index of lean (non-fat) mass, or impedance analysis. This impendence
depends on the difference in electrical resistance between lean tissue and fat.
Normal body fat content of an adult is 10-20% in men and 20-30% in
women.
The techniques involved are relatively complex and cannot be used for
routine clinical purpose or for epidemiological studies. Abdominal fat can be
measured using CT or MRI.
The introduction of measuring fat cells has opened up a new field in
obesity research.
Above all just a simple look towards an undressed patient is sufficient to
diagnosis the condition.
Morbidity and Mortality:
Greater the obesity higher the morbidity and mortality rates8. For
example, men who are 10% over weight have 13% increased risk of death, while
increase in mortality for those 20% over weight is 25%. The raise is less in
women and in men over 65 obesity is not an independent risk factor. Weight
reduction reduces this mortality and therefore should be strongly encouraged.
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55
Complication of Obesity
The following are the list of complications of Obesity11:
Type 2 diabetes mellitus
Hypertension
Stroke
Hyperlipidemia
Coronary heart diseases
Gall stones
Arthritis of hip, knee and foot
Varicose veins
Breathlessness
Sleep apnoea
Infertility
Hirsutism
Abdominal hernia
Depression
Cancers of breast, endometrium, ovaries etc.
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TREATMENT
The treatments of Obesity can be studied under the following heading:
1. Non-pharmacological measures including dietary control and Behavioral
Modification
2. Pharmacological measures
3. Surgical measures.
1. Non-pharmacological measures:
☻Dietary control:
This largely depends on a reduction in calorie intake. The most common
diets allow a daily intake of approximately 4200 k joules (1000 k cal), although
this may need to be nearer 6300 k joules (1500 k cal) for someone engaged in
physical work12. A diet that is too low in total calories will usually result in the
patient cheating and keeping to the diet only for short periods. Patients must
realize that prolonged dieting is necessary for large amounts of fat to be lost. A
permanent change in eating habits is required to maintain the new low weight. It
is relatively easy for most people to lose the first few kilograms, but long-term
success in moderate obesity is poor, with an overall success rate of no more than
10%.
The aim of any dietary regimen is to lose approximately 1 kg per week.
Weight loss will be greater initially owing to accompanying protein and
glycogen breakdown and consequent water loss. After 3-4 weeks, incremental
weight loss may be very small because only adipose tissue is broken down and
there is no accompanying water loss.
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57
Patients must understand the principles of energy intake and expenditure.
The best results are obtained in educated, well-motivated patients.
An increase in exercise will increase energy expenditure and should be
encouraged - provided there is contra-indication – since weight is usually not
achieved without exercise. Weight cannot be lost by exercise alone. Regular
exercise, however, will improve general health and often enables patients to
control their diet.
The diet should contain adequate amount of each nutrient. A diet of 1000
kcal per day should be made up of approximately 100 gm of carbohydrate, 50
gm of protein and 40 gm of fat. The carbohydrate should be in the form of
complex carbohydrate such as vegetable and fruit rather than simple sugars.
Alcohol contains which provides 7 kcal per gm, should be discouraged. A
balanced diet, attractively presented, is of much greater value and safer than any
of the slimming regimens.
☻ Exercise:
An increase in exercise will increase energy expenditure and should be
encouraged - provided there is contra-indication – since weight is usually not
achieved without exercise. Weight cannot be lost by exercise alone. Regular
exercise, however, will improve general health and often enables patients to
control their diet.
☻Behavioral Modification:
Behavior therapy is a term, which covers wide variety of treatment at
approaches. This therapy is based on an attempt to produce permanent changes
in behavior by involving the patient in his own management. Obese persons are
addicted by some behavioral pattern. This living pattern invites obesity, so that
this therapy guides the patients to observe his current life style, eating habit,
activities etc, and encourage changing it. The programs includes monitoring
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58
intake, modifying causes that signal “inappropriate eating”, modifying the act of
eating itself, increasing exercise and self reward for more appropriate behavior.
Self monitoring means keeping a written record of every thing eaten, the
circumstances in which it was eaten.
Elimination the case that signal inappropriate eating including controlling
the environment in which the person is e.g. changing habit such as watching TV
or studying, eating at late nights. These are all common problems of an obese
person.
Most obese people oscillate in weight; they often regain the lost weight,
but many manage to lose weight again. This cycling in body weight may play a
role in the development of coronary artery disease.
2. Pharmacological measures:
The following table (no.17) shows the drugs, their mode of action and
adverse effects:
DRUG ACTION ADVERSE EFFECTS Fenfluramine Acts through serotinergic
system in brain Primary HTN Valvular heart disease
Dexfenfluramine As above As above
Phentermine Acts centrally by reducing appetite
As above
Sibutramine Reuptake inhibitor of Norepinephrine
Cannot be used for long term
Orlistat Inhibition of intestinal lipase- malabsorption of fat
Cannot be used for long term
All these drugs can be used in the short term (max. of three months) as an
adjunct to the dietary regimen6.
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59
Some of the researches are going on β3-Adrenergic receptors agonists
may provide a new ray of hope for obese patients.
Surgical Measures:
Surgery to obese patients is indicated when their BMI exceeds 40.
Operations that involve bypassing parts of the small intestine have fallen out of
favour because of their side effects. Three procedures are in practice in the
condition of morbid obesity.
1.Wiring the jaws to prevent eating by which only liquids are allowed to
consume.
2.Gastric plication through which a pouch is constructed by stapling across
the wall of the stomach.
3.Gastric balloon is placed endoscopically inside the stomach and inflated.
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Nirukthi:
The word Udvarthana is derived from the root
ud + vrith + bhavae + karaneva lyud
This means vilepana or Gharshana.
Paribhasha:
In simple words, Udvarthana means rubbing of the body. It is a cleaning
procedure. It cleans Mala of skin by using drugs of fragrance.
It is described as one of the Rookshana karma. The word meaning of
Rookshana is making thin or the art of making thin. Acharya Charaka explains
this Rookshana as one among the Shadvidhopakrama. The drugs having the
qualities of Rooksha, Laghu etc are used for the procedures of Rookshana1. The
characteristic feature of Rookshana karma is that it surely prevents the outflow
of substance irrespective of the nature of their mobility1a.
Many a times Langhana karma is confused with Rookshana karma
because of much similarity of guna of both the dravya and similarities in the
treatment effects.
Table no.18 shows the difference between Langhana and Rookshana
Langhana Rookshana Gourava abhava Sneha abhava
Laghu guna pradhana Rooksha guna pradhana
Dravya & adravya bhuta(ex.upavasa) chikitsa Only dravya bhuta chikitsa
Sara guna present in drugs Sthira guna present in drugs
The dravyas of Rookshana karma will be dominated with Vayu pradhana,
Agni and pruthvi mahabhuta2 and it is having kashaya pradhana, katu tikta rasa.
The examples are yava and takra.
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Table no 19 showing various effects of Rookshana karma:
Effects
Dosha Vata vardhaka, Kapha nashaka
Dhatu Vikruta Dhatu soshana, Balya, Varnya
Mala Shoshana (dravamsha of mala)-performs sthambhana karma
Friction of body with brick powder excites the heat of skin, destroys
itching and rashes etc.
2. Utsadana (Rubbing):
It is defined as: “Sasneha Kalkenodgarshanam Utsadanam”
i.e. friction of body with drugs containing sneha or medicine mixed with oil or
other dravya in the form of kalka is called as Utsadana. The benefits of this are:
it improves complexion of females, gives good appearances, cleanliness, and
beautification.
Difference between Abhyanga and Udvarthana:
The main difference of Udvarthana from Abhyanga is that Udvarthana is
done in upward direction (prathiloma gathi) and Abhyanga is done in downward
direction (anuloma gati). However the main intention behind Udvarthana is to
bring the Rookshana in the body.
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The procedure that mimics the Udvarthana is Mardhana:
Acharya Dalhana comments Mardhana as:
“ Mardhanam tu gatam padabyama arambham kati parayatham”.
i.e. Mardhana is a process of giving deep pressure from foot to waist, which is in
prathiloma gathi. However Mardhana is being considered as a type of Abhyanga
(as sneha dravya are used).
Over all the benefits of Udvarthana as mentioned in different classical
texts are as follows:
Table no.23 Showing benefits of Udvarthana:
Sl. No.
Benefits Cha. Sam
Su Sam
As. Hr.
Yg. Ra
1 Dourgandya hara + - - -
2 Gourava hara + - - -
3 Tandra hara + - - -
4 Kandu hara + - - -
5 Mala hara + - - -
6 Aruchi hara + - - -
7 Vata hara - + - -
8 Kapha vilayana - + - -
9 Meda vilayana - + + -
10 Anga sthirikarana - + + -
11 Twak prasadakara - + + +
12 Kapha hara - - + +
13 Meda hara - - - +
14 Shukrada - - - +
15 Balya - - - +
16 Kanthi - - - +
17 Twak mrudutwa - - - +
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Rubbing – Mode of Action
Rubbing helps in the absorption of effusions, relief of blood stasis and
carrying away the morbid products in the system. Deep pressure massage helps
the interchange of tissue fluids by increasing the circulation in the superficial
vein and lymphatics. The pressure helps the contents of the vessels move
towards the heart, if applied strongly and quickly, it has a stimulating effect. It
increases nutrition in all tissues. It removes fatigue, carrying away the increased
products of combustion. Also it assists the reabsorption of serous fluid.
Important qualities of rubbing are –
It has got great influence on the muscles. It gives them a mechanical
stimulation causing them to contract
It increases circulation mainly in the veins. The alternate pressure and
relaxation brings fresh blood to the part
It improves the nutrition of the particular area
It raises temperature locally
It increases elimination of waste products
It increases secretion and absorption
It improves the condition of the nervous system by stimulating the cutaneous
nerve endings
It influences the general metabolism when applied on large areas
Helps to breakdown thickening and adhesions in subacute and chronic
conditions
Also helps in the reabsorption of inflammatory products and absorption of fat
in fatty tissues.
When rubbing is done lightly on the nerves for a short time it stimulates them.
If applied down on each side of the spinal column, stimulates the spinal nerves and
in a reflex way strengthens the heart. It affects the vasomotor nerves and there by
widens the blood vessels also influences the secretary nerves for increasing their
function.
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Physiological effect of rubbing
The pressure of deep massage exerts a simultaneous influence up on all
the tissue of the body with in it reach up on the skin, fasciae, muscles, peripheral
nerves, blood vessels, lymphatic and central nervous system. Further it
accelerates the activity of the heart, helps the assimilation of food and influences
general metabolism of the body. As the skin covers nearly the whole body its
surface is affected by massage as well as the structures, which lie beneath it. It
increases the cutaneous circulation and benefits the sensory nerve ending and
influences the vasoconstrictors and vasodilators in the skin.
The effect of rubbing up on muscle tissue is of vast importance. This
effects removal of fatigue products. Muscles in action exert a kind of massage up
on each other. Ordinary movements of the voluntary muscle are a means of
accelerating the blood by their alternate contractions and relaxations. At every
contraction blood is pressed out of the muscle, at the same time it receives an
impulse to return to the heart, while during each relaxation fresh blood comes to
the muscle. Muscular fatigue from over exertion is relieved by massage. Toxic
materials must be removed from the tissues in order to restore the normal
functions of the body and this can be accomplished by rubbing.
Influence of rubbing up on the circulation of fluid is also of great
importance. Both the venous and lymphatic circulations are accelerated towards
the heart. Deep manipulations cause the veins and lymphatic to be mechanically
emptied and the fluid cannot return on account of the valves within the vessels.
More space is thus made for blood returning from the deeper parts.
The rubbing may be said to act both by pressure and by suction. Massage
diminishes the blood pressure without increasing the activity of the heart. But
the blood vessels are relaxed, distended and stretched by this. After a course of
this treatment blood has been found to contain more red blood corpuscles and
Review of literature-Udvarthana
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hemoglobin. These are not manufactured by rubbing. But brings them into
circulation instead of them remaining dormant in the system.
Lymph flow is helped by rubbing exercises for the limbs both passive and
active increases the lymph flow. But prolonged inactivity tends to impend
normal nutrition because of defective drainage by lymphatic.
Rubbing stimulates both motor and sensory nerve endings to various parts
of the body. This stimulation is carried along the sensory fibers of a nerve to the
spinal cord and hence to the brain. There it is transmitted through another set of
fibers to the same part and this is the reflex action of the nerve or spinal cord is
diseased or impaired. So that the communication is completely cut off, no such
action results. The activity of motor nerves is increased by strong pressure. It is
diminished or destroyed. A strong stationary pressure on the affected muscle
may stop cramps. Rubbing stimulates secretary nerves. This also influences
vasomotor neurons. A short gentle stimulation applied to nerves containing both
vasoconstrictors and vasodilators tends to produce a contraction of blood vessels
but a strong and continuous stimulation will produce dilatation, the skin becomes
red and the part feels warms. Rubbing is an excellent form of passive exercise. It
is a part of physiotherapy, which will relieve pain, improves the strength and
mobility.
Motion of the molecules participates in chemical activity. It is known that
all materials participating in nutrition and support of the vital powers undergo
radial chemical changes in their course through the organism and that it is only
by and through these chemical process of composition and decomposition that
the evolution of vital power in any of its form is possible. The motion of the
circulating fluids, vascular and intervascular is necessary to bring the elements
for chemical change. Motions secure impact between the separate and distinct
molecules. This impact converts motor into chemical energy. The special and
energetic use of pressure motions is therefore the first and natural means adapted
to overcome the effects. Ill health co-exists with the presence of sub-oxides, and
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that the degree of health, is measured by degree in which the oxidizing purpose
of the system is attained. The true remedial relevancy of rubbing is readily seen,
since its purpose and effects is to increases the degree of oxidation, to convert
sub-oxides into complete oxides, which only are compatible with health.
Procedure of Udvarthana
The best time for Udvarthana is in the early morning between five and nine.
Because in daily regimen it is mentioned before snana.
Before doing Udvarthana, bladder and bowel should be emptied.
Blood pressure, pulse rate, heart rate and respiratory rate should be recorded
before doing Udvarthana.
Udvarthana is started from legs, arms, chest, abdomen, back and gluteal
region and is done in upward direction.
Generally, duration is 30 to 45 minutes.
After Udvarthana, patient should take rest for 5 to 10 minutes, which helps
the patient to relax.
After relaxation, hot water bath is taken.
Clinical Study
Effect of Udvarthana in Sthoulya
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Research Design:
Present study is a two group clinical study with pre-test and post-test
design.
Setting for the Study:
The scholar had selected the out patient department of Sri Dharmasthala
Manjunatheshwara Ayurveda Hospital, Hassan as the setting for the study.
Population:
Obese patients from all over Hassan district and other neighbouring
districts and states who attended the Hospital were included in the study.
Sample:
The samples were selected from the population consisting of adult
patients of either sex, irrespective of religion, race, socio-economic status and
education, satisfying the inclusion criteria.
Grouping:
A total number of 30 samples were selected and randomly allocated into
following groups.
Group - A: Control group consisted of 15 patients, who were instructed to
follow the advised exercises and a calorie calculated dietary chart. The patients
were given Rechana (Purgation) with Trivruth lehya.
Group-B: Experimental group consisted of 15 patients, who were given
Rechana with Trivruth lehya followed by Udvarthana with Triphaladi choorna
for 7 days. The method of preparation of Triphaladi choorna is discussed in drug
review context. After completion of Udvarthana again Rechana was given with
Trivruth lehya. Here also the patients were asked to follow exercises and a
Clinical Study
Effect of Udvarthana in Sthoulya
72
calorie calculated dietary chart similar to that of Group A, except on the days of
purgation.
The samples were under direct observation of the investigator for the first
9 days of their hospital stay and then onwards they were asked to visit hospital
after 1 month for follow-up.
Hypothesis:
Null-hypothesis: Udvarthana is not effective in reducing weight.
Alternate –hypothesis: Udvarthana is effective in reducing weight
Reasons for selecting the Research design:
For a scientific trial, proper design is required so as to assess the efficacy
of the therapy, in turn to meet the objectives. Here two groups i.e. Group-A and
Group-B have been selected. Except Udvarthana, all the treatment modalities
like purgation, physical exercise and diet were common for both the groups.
Hence Group-B will highlight the efficacy of Udvarthana.
As it has already been discussed that sthoulya is a multifactorial disease
and a holistic approach is required for the same, so the modalities like exercise,
Udvarthana and diet have been included in the study. Moreover, no treatment is
completed unless proper Ahara and Vihara are followed along with the
medicine.
Pathya in terms of calorie calculated diet is having its own role. Hence a
diet chart, which provides energy, that is just a little more than that of the Basal
Metabolic Rate (BMR) i.e. 1200 to1400 kcal is allowed to the patients. The
concepts like low fat and high fibers have been considered while preparing the
chart. As the samples were not just restricted to a small geographical area, this
chart was modified keeping in view their Desha, Satmya, kala and udyoga.
Clinical Study
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However a standard diet chart is enclosed in annexure, considering their nature
of food habits and calorie.
Proper dynamic exercises are required to burn off the calories present in
the body in the form of adipose tissue. All the 30 patients were advised to follow
dynamic exercises for duration of one hour in morning and evening on all the
days of the study in the hospital except on the day of purgation and subjects
were advised to follow the same at their house after discharge. The list of
exercises is enclosed in annexure. The samples underwent Physiotherapy
exercises as advised, which included stepper, tread-mail, shoulder-wheel, pulley,
vibrator, cycle, etc.
Sweda is believed to be the mala of meda dhatu; hence to remove excess
sweda from vikrutha medas, swedana karma in the form of Sarvanga bashpa
sweda has been done to the patients following Udvarthana.
As it is a medavrita vata janya vyadhi, after vilayana of medas through
Udvarthana, to check the vikrutha Vata, Rechana was given for the purpose of
Vatanulomana.
Udvarthana was selected for Group B patients on the basis of the
assumption that it can initiate the process of lipolysis and helps in the
transportation of lipids from the periphery to the liver, where it will be
metabolized into fatty acids to yield energy. On this hypothesis the present study
has been designed.
This study has been designed after conducting sufficient number of pre-
clinical trials and during which no adverse effects were noticed; therefore the
study was taken up for detailed analysis.
No internal medicines were advised for the patients. All the patients of
each Group were asked to come for follow up after one month. Keeping in view
Clinical Study
Effect of Udvarthana in Sthoulya
74
of practical problems and limitations of time, the investigator has bonded
himself for one month observations to check further changes in the weight. The
sample size in both the groups were small i.e. 15 patients, but considering the
time limitation and the technical problems, the scholar had restricted himself for
a total of 30 patients.
Objectives of the Study:
1. To study the concept of sthoulya as per the Ayurvedic texts and their
discussions with current medical prospective.
2. To evaluate the effect of Udvarthana as the therapeutical aid in the
patients of sthoulya (in terms of weights and biochemistry).
3. To see the effect of Udvarthana in relieving the associated symptoms like
Atisweda, Dourgandhya etc.
4. To survey the obese patients attending the O.P.D of S.D.M.C.A&H,
Hassan, irrespective of their complaints.
Selection Criteria:
Inclusion Criteria:
1. Patients complaining of symptoms related to sthoulya as per the classics.
2. Patients who were already diagnosed as obese.
3. Patients not responding to the expectations with textual prescription
irrespective of system of medicine.
4. Patients who’s Body Mass Index is equal or above 30, irrespective of sex.
5. Patients of uncomplicated hypertension and arthritis who are under
control and under treatment were also selected for study.
6. Obese patient detected or diagnosed to be having Hyperlipidemia.
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Exclusion Criteria:
1. Obesity due to other disorders like secondary obesity as seen in Cushing
syndrome, Hypothyroidism etc.
2. Patients with previous history of cardiac disorders and other systemic
disorders.
3. Obesity observed since birth were excluded.
Assessment criteria:
Assessment was made based on subjective and objective parameters is as
follows:
Objective parameters:
1. Weight
2. BMI
3. Circumference of Chest, Abdomen, Hip, Mid-arm, Mid-thigh
Subjective parameters:
Various features of obesity had been considered and grading was given to
analyze the results statistically as follows.
1. Assessment of chala spik, stana and Udara
a. Absence of chalatva grade 0
b. Chalatva during fast movement grade 1
c. Chalatva during moderate movement grade 2
d. Chalatva during slight movement grade 3
2. Assessment of Ayata upachaya, utsaha hani (sluggish movement of body)
a. Unimpaired utsaha grade 0
b. On desire can work sluggishly but properly grade 1
c. On desire can work sluggishly but improperly grade 2
d. Even on desire do not like to work grade 3
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3. Assessment of Sweda adikyata (At normal condition and at comfortable zone i.e.
temperature of 270 c, humidity of 65%)
a. No sweating grade 0
b. Profuse sweating after moderate work grade 1
c. Profuse sweating after slight work grade 2
d. Sweating even in resting condition grade 3
4. Assessment of Ayase Swasa (dyspnoea on exertion)
a. Absent grade 0
b. Dyspnoea on moderate work grade 1
c. Dyspnoea on slight work grade 2
d. Dyspnoea even at rest grade 3
5. Assessment of Nidradhikya (excessive sleep)
a. Normal sleep of 6-7 hours per day grade 0
b. Normal sleep of 8 hours per day grade 1
c. Normal sleep of 10 hours per day grade 2
d. Normal sleep of more than 10 hours per day grade 3
6. Assessment of Athi kshudha (excessive hunger)
a. Feels hunger at next annakala only grade o
b. Feels hunger for once in between Anna kala grade 1
c. Feels hunger for more than twice grade 2
d. Feels hunger always grade 3
7. Assessment of Ahara matra (total quantity of food intake)
a. Takes food in moderation grade 0
b. Takes one time food up to satiety grade 1
c. Takes two times food up to satiety grade 2
d. Takes food always up to full satiety grade 3
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8. Assessment of Ahara kala (frequency of food intake)
a. Two large meals a day grade 0
b. One small meal and two large meals a day grade 1
c. Three large meals a day grade 2
d. More than three meals a day grade 3
9. Assessment of kshudha souhitya (feeling of satiety after food)
a. Feels comfort after food grade 0
b. Feels discomfort but performs routine work grade 1
c. Feels discomfort and hampers routine work grade 2
d. Feels discomfort and unable to perform work grade 3
10. Assessment of kshudha sahatva (tolerance of hunger)
a. Can tolerate hunger more than two meal time grade 0
b. Cannot tolerate hunger more than two meal time grade 1
c. Cannot tolerate hunger more than one meal time grade 2
d. Cannot tolerate hunger even for one meal time grade 3
11. Assessment of Athi Pipasa (excessive thirst)
a. Normal thirst grade 0
b. Up to one liter excess intake of water / fluids grade 1
c. Up to two-three liter excess intake of fluids grade 2
d. More than three liter excess intake of fluids grade 3
12. Assessment of Alpa vyayama (decreased physical exercises)
a. Can do routine exercises grade 0
b. Can do moderate exercise with difficulty grade 1
c. Can do only mild exercises with difficulty grade 2
d. Cannot even do mild exercises grade 3
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13. Assessment of Alpa vyavaya (decreased sexual attitude)
a. Unimpaired libido and sexual performance grade 0
b. Decreased libido but can perform sexual act grade 1
c. Decreased libido, sexual act with difficulty grade 2
d. Loss of libido and cannot perform sexual act grade 3
14. Assessment of Anga gourava (feeling of heaviness)
a. No heaviness in body grade 0
b. Feels heaviness but it doesn’t hampers routine work grade 1
c. Feels heaviness which hampers routine work grade 2
d. Feels heaviness which restricts routine work grade 3
15. Assessment of Anga sithilatha (flabbiness of body)
a. No flabbiness in body grade 0
b. Flabbiness in one anatomical region grade 1
c. Flabbiness in more than one region grade 2
d. Generalized flabbiness in body grade 3
16. Assessment of Gatra sada (fatigue)
a.can perform work without fatigue grade 0
b. can perform work with little fatigue grade 1
c. can perform work with Moderate fatigue grade 2
d. can’t perform any work grade 3
Materials:
The following materials are required for the clinical study:
Triphaladi Udvarthana Choorna
Trivruth lehya
Weighing machine
Measuring tape
Clinical Study
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Drug Review In the present study some of the drugs, which are having Rookshana property had been selected. The following tables shows the important features of the drug which are used for Udvarthana choorna
Drug Latin name
Kula (Family)
Paryaya Rasa Guna Virya Vipaka
Haritaki Terminali-a
chebula
Haritaki (combretacea
e)
Abhaya Pathya Rohini
Lavana varjitha
pancharas Kashaya
rasa Pradhana
Laghu Ruksha
Ushn Madhur
Amlaki Emblica officinalis
Euphorbiace-ae
Dhatri Amlaja.
Lavana varjitha
pancharas Amla rasa
Pradhana
Guru Ruksha Sheeta
Sheet Madhur
Vibitaki Terminali-a belirica
Combretace-ae
KarshaphalaAksha
Kalidruma
Kashaya Laghu Ruksha
Ushn Madhur
Mudga Vigna radiata
Shimbi (leguminosa
-e)
Kashaya Madhura
Laghu Ruksha
Sheet Katu
Kulatha Cassia absus
(leguminosa-e)
Chakshyus-ya
Kulali
Tikta, Kashaya
Ruksha Sheet Katu
Sarshap Brassica compestri
Ragika (cruciferae)
Katusneha Tantubha
Katu Tikta
Tikshna Snigda
Ushn Katu
Methika Trigonella foenum
Shimbi (leguminosa
-e)
Pitabeeja Katu Laghu Snigda
Ushn Katu
Yava Hordeum vulgarae
(gramineae) Java Madhura Kashaya
Laghu-
Ruksha Sheet Katu
Clinical Study
Effect of Udvarthana in Sthoulya
80
Dravya Chemical Composition
Bhahya Prayoga Dosha -gnata
Rogagnata Prayojya Anga
Haritaki Chebulagic acid, Tannin Corilagin
Shothahara, Vrana Shodhana Vedanasthapana
VPK Srotoshodana Prameha, kusta
Arsha,
Phala
Amlaki Gallic acid Tannic acid, Vit-c
Dahaprashamana Chakshushya Keshya
VPK Prameha, Kusta,
Shotagna
Phala
Vibitaki Tannin Galic acid Ethyl gallate
Shothahara, Raktastambhana Vedanasthapana
VPK Kapha vikara Medo vikara, Rasa vikara
Phala
Mudga Potassium, Vitamin A,B,C,K
- PK Prameha, kusta Beeja
Kulatha Chaksine Isochaksine
Neetra roga
PK Medo roga Ashmari
Beeja
Sarshap Sinalbin, Sulphosianide
Lekhana Varnya Vedanasthapana
VK P
Kusta Beeja Taila
Methika Volatile oil, Calcium
Vedanasthapana Shothahara
VK
Shotha, Vidradhi
Panchang
Yava Protein, Iron Calcium Phosphorus
- PK V
Mutrakruchra Prameha, Kasa
Trishna,Peenasa
Panchang
V-Vata, P-Pitta, K-Kapha, -Prakopa, - Shamana
Table – showing the ingredients and their quantity in Triphaladi choorna.
The drugs and their proportions have been standardized after pilot study.
Clinical Study
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81
Source of Drugs
All the raw drugs for the preparation of Udvarthana choorna were
procured from S.D.M College of Ayurveda Pharmacy, Hassan.
Preparation of Udvarthana Choorna
All the ingredients in suitable proportions are made into sukshma choorna
separately then they are mixed together.
Trivruth lehya:
This drug is used for Rechana (purgation) in both the groups.
Table showing the properties of Trivruth:
Latin name:
Family:
Paryaya:
Rasa:
Guna:
Veerya:
Vipaka:
Chemical composition:
Doshagnata:
Rogagnatha:
Operculina turpephum
convolvelaceae
Tribandi, Nishotha
Kashaya, Madhura
Rooksha
ushna
Katu
Turpethin, volatile oils
Kapha- pitta shamana
Jwara, Shotha, Udara, Pleeha, Pandu, Vrana
Trivruth lehya was taken from Arya Vaidya Sala, Kottakkal, Kerala.
Treatment Procedure:
After completion of exercises, the patients were made to lie on table with
minimal clothing. A total of 400 gm of Udvarthana choorna is taken every time.
Massage with this herbal powder was done in ‘pratiloma gati’ i.e. against the
direction of hair follicles. Massage was done in all following seven consecutive
postures for a period of 5 minutes in each, with a total duration of 35 minutes.
Clinical Study
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82
1. Sitting
2. Supine
3. Left lateral
4. Dorsal
5. Right lateral
6. Supine
7. Sitting
After Udvarthana, the subjects underwent Sweda karma (Sarvanga bashpa
Sweda with Dasha moola kwatha).
Materials for diagnostic study:
To measure circumference of mid-arm, mid-thigh, abdomen, chest and
hip, measuring tape was used. A standard Weighing machine was used to
measure weight and it is noted in kg.
Materials for laboratory investigations:
The investigations are carried out in an “Auto analyzer”. Lipid profile test
was done before and after treatment, in empty stomach. This test includes
Total cholesterol
HDL
Triglycerides
LDL {= TC – HDL – (Triglycerides / 5)}
The following table shows the name of the reagents used for the study.
Test Name of the reagent Maker
Total cholesterol Total cholesterol liquid kit Diagnostica, Bantwal.
HDL HDL cholesterol precipitating set Diagnostica, Bantwal.
Triglycerides Triglyceride liquid reagent set Diagnostica, Bantwal.
Clinical Study
Effect of Udvarthana in Sthoulya
83
Before Udvarthana
During Udvarthana with Triphaladi choorna
1
2
Observation & Results
Effect of Udvarthana in Sthoulya
83
Technological efficacy of sciences has lead to wide acknowledgement of
effectiveness of its method. Standards of testability, verifiability and more
refined criteria of falsifiability as filters for legitimate knowledge have been
brought about by ceaseless development of science. Ingenuity of science is seen
in its method. It is experiments that give impetus to scientific knowledge.
For any research work, the data should be collected systemically and must
be presented in such a way that the reader can understand the things in a better
manner.
Here onwards the data will be presented in tabulations, graphs and
pictographs. As these are self-explanatory descriptions are given wherever
required.
Observations:
Table no.24 Showing Age-wise Distribution of Sthoulya Cases in Group A & B:
Age Group Group A % Group B % Total % 18-30 05 33.33 03 20.02 08 26.66
31-40 05 33.33 04 26.66 09 30.00
41-50 03 20.01 04 26.66 07 23.34
51-60 02 13.33 04 26.66 06 20.00
61-70 00 00.00 00 00.00 00 00.00
71-80 00 00.00 00 00.00 00 00.00
Total 15 15 30
Table no.25 showing sex wise distribution:
Sex Group A % Group B % Total %
Male 07 46.67 05 33.33 12 40.00
Female 08 53.33 10 66.67 18 60.00
Total 15 15 30
Observation & Results
Effect of Udvarthana in Sthoulya
84
Chart- Showing Agewise distribution of obese patients:
0123456789
no.of patients
Group A Group B Total
18-30
31-40
41-50
51-60
61-70
71-80
Chart- Showing sex wise distribution:
75
12
810
18
0 5 10 15 20 25 30 35
Group A
Group B
Total
Male Female
Chart- Showing Distribution of Associated Features in both Groups:
0
5
10
15
20
25
30
35
Group A Group B TotalPipasa Kshuda Swasa Dourgandhya
Athi Sweda Srama Athi Nidra
Observation & Results
Effect of Udvarthana in Sthoulya
85
Table no.26 Showing Distribution of Sthoulya Cases in Group A and B
according to Religion:
Religion Group A % Group B % Total %
Hindu 11 73.34 12 73.34 23 76.67
Muslim 03 19.99 03 19.99 06 20.00
Christian 01 06.67 00 06.67 01 03.33
Total 15 15 30
Table no.27 Showing Distribution of Sthoulya Cases in Group A and B
according to Socio-economical status
Status Group A % Group B % Total % Low 00 00.00 00 00.00 00 00.00
Middle 06 40.00 05 33.34 11 36.66
High 09 60.00 10 66.66 19 63.34
Total 15 15 30
Table no.28 Showing Distribution of Sthoulya Cases in both Groups occupation:
Occupation Group A % Group B % Total % House wife 04 26.66 08 53.31 12 40.00
Business 04 26.66 02 13.34 06 20.00
Clerk 03 20.00 01 06.67 04 13.33
Teacher 02 13.34 01 06.67 03 10.00
Engineer 01 06.67 01 06.67 02 06.67
Student 01 06.67 02 13.34 03 10.00
Total 15 15 30
Table no.29 Showing Distribution of Sthoulya Cases in Group A and B as per
Prakruthi:
Prakruthi Group A % Group B % Total %
Vata-Kapha 09 60.00 10 66.67 19 63.34
Pitta-Kapha 06 40.00 05 33.33 11 36.66
Total 15 15 30
Observation & Results
Effect of Udvarthana in Sthoulya
86
Table no.30 Showing Distribution of Sthoulya Cases in both Groups according
to chronicity:
Chronicity (In Years)
Group A % Group B
% Total %
Less than 10 10 66.66 10 66.66 20 66.66
11-20 03 20.02 02 13.34 05 16.66
21-30 01 06.66 02 13.34 03 10.00
31-40 01 06.66 00 00.00 01 03.34
41-50 00 00.00 01 06.66 01 03.34
Total 15 15 30
Table31 Distribution of Sthoola in both Groups according to Family history
Family History Group A % Group B % Total %
Negative 02 13.34 02 13.34 04 13.34
Maternal +ve 05 33.34 05 33.34 10 33.34
Paternal +ve 02 13.34 03 19.98 05 16.66
Both +ve 06 39.98 05 33.34 11 36.66
Total 15 15 30
Table no.32 Showing Distribution of Sthoulya Cases in Group A and B as per
quantity of food consumption:
Quantity of Food
Group A % Group B % Total %
Less 00 00.00 00 00.00 00 00.00
Moderate 04 26.66 06 40.00 10 33.34
More 11 73.34 09 60.00 20 66.34
Total 15 15 30
Observation & Results
Effect of Udvarthana in Sthoulya
87
Table no.33 Showing Sthoola in both groups according to frequency of food
consumption:
Frequency of food intake
Group A
% Group B
% Total %
2 times 00 00.00 00 00.00 00 00.00
3 times 03 20.00 07 46.67 10 33.34
4 or more 12 80.00 08 53.33 20 66.34
Total 15 15 30
Table no.34 Showing Distribution of Sthoulya Cases in both Groups as per
Pana”:
Pana Group A % Group B % Total % Sitambu 12 80.00 09 60.00 21 69.99
Fruit juice 13 86.00 10 26.67 23 76.67
Butter milk 02 13.34 04 26.34 06 19.99
Dumra pana 04 26.67 02 13.34 06 19.99
Madhyapana 01 06.67 02 13.34 03 09.99
Total 15 15 30
Table no.35 Showing Sthoola Cases in both Groups per Rasa preferred:
Rasa Group A % Group B % Total %
Madhura 14 93.34 12 80.00 26 86.67
Amla 09 60.00 05 33.34 14 46.67
Katu 07 46.67 11 73.34 18 59.99
Total 15 15 30
Table no.36 Showing Distribution of Sthoulya Cases in Group A and B
according to “Nidra kala”:
Nidra kala in hrs Gr A % Gr B % Total %
10 or more 09 60.00 10 66.67 19 63.34
Less than 10 06 40.00 05 33.33 11 36.66
Total 15 15 30
Observation & Results
Effect of Udvarthana in Sthoulya
88
Table no.37 Showing Distribution of Sthoulya Cases in Group A and B as per
Adhyatana Agni:
Adyatan agni Group A % Group B % Total %
Pravara 15 100 13 86.67 28 93.34
Madhyama 00 00.00 02 13.33 02 06.66
Avara 00 00.00 00 00.00 00 00.00
Total 15 15 30
Table no.38 Showing Distribution of Sthoulya Cases in Group A and B as per
Poorvagni:
Poorvagni Group A % Group B % Total %
Pravara 08 53.34 14 93.33 22 73.34
Madhyama 07 46.66 01 06.67 08 26.66
Avara 00 00.00 00 00.00 00 00.00
Total 15 15 30
Table no.39 Showing Distribution of Sthoulya Cases in Group A and B as per
Abhyahvarana shakthi:
Abhyavaran Shakthi
Group A
% Group B
% Total %
Uttama 12 80.00 13 86.67 25 83.34
Madhyama 03 20.00 02 13.33 05 16.66
Hina 00 00.00 00 00.00 00 00.00
Total 15 15 30
Table no.40 Showing Sthoola in both Groups as per Jarana shakthi
Jarana Shakthi Group A % Group B % Total % Uttama 14 93.34 12 80.00 26 86.67 Madhyama 01 06.66 03 20.00 04 13.33 Hina 00 00.00 00 00.00 00 00.00 Total 15 15 30
Observation & Results
Effect of Udvarthana in Sthoulya
89
Table no.41 Showing Distribution of Sthoola in both Groups as per Jatha Desha:
Subjective parameter Gp I II III IV V A 1.53 1.93 1.13 1.33 2.53 Mean BT B 1.80 2.06 1.26 1.46 2.40 A 1.40 1.33 1.13 1.20 1.60 Mean AT B 1.40 1.26 1.20 1.06 1.33 A 0.133 0.60 00 0.133 0.933 Mean dif. B 0.40 0.80 0.06 0.40 1.066 A 8.49 31.08 00 9.77 36.75 Mean % of
Improvement B 22.22 38.83 4.76 27.39 44.16 A 0.339 0.489 0.0 0.339 0.573 S.D B 0.489 0.748 0.249 0.611 0.679 A 0.087 0.126 0.00 0.087 0.147 S.E B 0.123 0.193 0.064 0.157 0.175 A 1.519 4.754 00 1.528 6.349 “t” valve B 3.252 4.142 1.028 2.536 6.081 A < 0.2++ <0.001** 1++ <0.2++ <0.001** “p” value B <0.010* <0.001** <0.4++ <0.02+ <0.001**
Observation & Results
Effect of Udvarthana in Sthoulya
97
Subjective parameter Gp VI VII VIII IX X A 1.93 2.66 2.66 2.73 2.8 Mean BT B 1.66 2.60 2.60 2.73 2.60 A 1.60 1.40 0.66 1.00 1.26 Mean AT B 1.13 1.26 0.60 0.56 0.86 A 0.33 1.26 2.00 1.60 1.53 Mean dif. B 0.53 1.33 2.00 2.06 1.73 A 17.09 47.36 75.18 58.60 54.64 Mean % of
Improvement B 31.92 51.15 76.92 75.54 51.15 A 0.471 0.442 0.00 0.489 0.570 S.D B 0.618 0.596 0.730 0.470 0.573 A 0.121 0.114 0.00 0.126 0.147 S.E B 0.157 0.153 0.188 0.121 0.147 A 2.738 11.09 0.00 12.698 10.428 “t” valve B 3.394 8.667 10.615 17.074 11.717 A < 0.025+ <0.001** 1++ <0.001** < 0.001** “p” value B <0.005+ < 0.001** <0.001** < 0.001** < 0.001**
Subjective parameter Gp XI XII XIV XV XVI A 2.20 2.06 1.80 2.20 1.33 Mean BT B 2.13 2.13 2.13 2.40 1.53 A 1.86 1.00 0.93 2.00 0.93 Mean AT B 1.86 0.60 0.66 1.80 0.86 A 0.33 1.06 0.86 0.20 0.46 Mean dif. B 0.26 1.53 1.46 0.53 0.66 A 13.63 51.45 47.77 9.09 34.58 Mean % of
Improvement B 12.20 71.83 68.54 22.08 43.13 A 0.471 0.249 0.498 0.40 0.498 S.D B 0.442 0.498 0.618 0.498 0.491 A 0.121 0.064 0.128 0.103 0.128 S.E B 0.114 0.123 0.159 0.128 0.126 A 2.738 16.656 6.739 1.937 3.626 “t” valve B 2.331 12.463 9.185 4.147 5.285 A < 0.025* <0.001** < 0.001** < 0.1+ < 0.005* “p” value B < 0.025* < 0.001** < 0.001** <0.001** < 0.001**
Observation & Results
Effect of Udvarthana in Sthoulya
98
Assessment of objective criteria:
Table no.64 showing changes of weight in both Groups:
S.No. Group A Group B BT AT Dif. BT AT Dif. 1 90 88 2 99 94 5
2 66 65 1 83 77 6
3 89 88 1 60 58 2
4 85 85 0 76 75.5 1.5
5 90 89 1 92.5 88 4.5
6 87 86 1 71 65.5 5.5
7 81 81 0 91 86 4 8 80 78.5 1.5 90 87.5 2.5
9 75 74 1 86 82 4
10 94 91.5 2.5 90 85 5
11 79 79 0 86 82 4
12 78 76.5 1.5 95 92 3
13 70 68 2 96 93 3 14 93 91 2 70 65.5 4.5
15 69 68 1 78 72 6
Total 1226 1208.5 17.5 1263.5 1203 60.5
Table no 65 showing response of weight in both groups:
Weight reduction Response Group A % Group B %
0-2 kg Poor 15 100 03 20.00
3-5 kg Moderate 00 00 10 66.66
6-8 kg Good 00 00 02 13.34
There was maximum of 2.5 and 6 kg difference in group A and B
respectively. 80% of subjects in group B had lost weight of more than 2 kg.
Observation & Results
Effect of Udvarthana in Sthoulya
99
Chart- Showing changes of weight in both Groups:
0
1
2
3
4
5
6
7
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
reduction in kg
Gr. A
Gr.B
Table no.66 showing changes of BMI in both Groups:
Table no.67showing response of BMI in both groups:
Changes in BMI Response Group A % Group B %
No change Poor 03 20.00 00 00
<1 Moderate 12 80.00 03 20.00
>1 Good 00 00.00 12 80.00
Observation & Results
Effect of Udvarthana in Sthoulya
100
0.97 was maximum reduction of BMI in group A and in group B 2.56. The least
reduction in group B is 0.21. In group A 80% of subjects reduced <1 BMI and in
group B 80% patients reduction in >1 BMI.
Chart- Showing changes of BMI in both Groups:
0
0.5
1
1.5
2
2.5
3
decrease in BMI
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
pts
Gr.A. Gr.B
Observation & Results
Effect of Udvarthana in Sthoulya
101
Table no.68 showing Statistical analysis of weight and BMI after treatment in
both groups:
Group Weight B M I A 81.73 32.83 Mean BT B 84.23 34.21 A 80.56 32.35 Mean AT1
B 80.20 32.58 A 79.13 31.78 Mean AT2
B 78.03 31.76 A 1.16 0.47 Mean dif.1
B 4.03 1.63 A 2.60 1.04 Mean dif.2
B 6.26 2.45 A 1.41 1.43 Mean % of
Improvement1 B 4.78 4.76 A 3.181 3.167 Mean % of
Improvement2 B 7.43 7.132 A 0.745 0.296 S.D1 B 1.347 0.650 A 1.26 0.496 S.D2 B 2.143 0.775 A 0.192 0.076 S.E1 B 0.3477 0.167 A 0.324 0.270 S.E2 B 0.553 0.631 A 6.223 6.223 “t” valve1
In above table, all parameters with “1” denotes value after 8 days of
treatment and “2” denotes value after one month of follow up.
Observation & Results
Effect of Udvarthana in Sthoulya
102
Table no.69 showing the response of both groups in chest circumference:
Response Changes in centimeters Group A % Group B %
Nil 0 13 86.66 00 00.00
Mild 1 02 13.34 08 53.34
Moderate 2 00 00.00 03 19.99
Good > 2 00 00.00 04 26.67
2 patients in group B showed maximum decrease of 2 cms in chest
circumference.
Table no.70 showing the response of both groups in abdomen circumference:
Response Changes in cm Group A % Group B %
Nil 0 05 33.33 01 06.67
Mild 1 08 53.33 03 19.99
Moderate 2 02 13.34 01 06.67
Good > 2 00 00.00 10 66.67
Patients of group B had responded well in decrease of abdomen
circumference. Maximum of 7 cms decrease was noticed in that group.
Table no.71 showing the response of both groups in hip circumference:
Response Changes cms Group A % Group B %
Nil 0 06 40.00 03 20.00
Mild 1 09 60.00 03 20.00
Moderate 2 00 00.00 05 33.34
Good > 2 00 00.00 04 26.66
There was good response in decrease of hip circumference in patients of
B group. Maximum decrease of 4 cms was noticed in one patient of group B
Observation & Results
Effect of Udvarthana in Sthoulya
103
Table no.72 showing the response of both groups in Mid-arm circumference:
Response Changes in cms Group A % Group B %
Nil 0 14 93.34 10 66.66
Mild 1 01 06.66 04 26.68
Moderate 2 00 00.00 01 06.66
Good > 2 00 00.00 00 00.00
Group A showed no response in 14 patients, where as group B had
responded relatively well. One patient had decrease of 2 cms in trail group.
Table no.73 showing the response of both groups in Mid-thigh circumference:
Response Changes in cms Group A % Group B %
Nil 0 08 53.33 02 13.34
Mild 1 05 33.33 07 46.66
Moderate 2 02 13.34 02 13.34
Good > 2 00 00.00 04 26.66
4 patients in group B had decreased their circumference of mid-thigh over
2 cms. Maximum of 3.5 cms decreased was noticed in that group.
Table no.74 showing Circumference of Chest, Abdomen, Hip, Mid-arm, Mid-
thigh statistical analysis:
Gr. Chest cir. Abd cir. Hip cir. Mid-arm cir
Mid-thigh cir
A 104.8 106.73 111.13 33.73 61.76 Mean BT B 107.93 111 114.36 33.7 61.76 A 104.66 105.93 110.53 33.7 61.26 Mean AT B 106.26 108.33 112.66 33.26 60.13 A 0.13 0.80 0.60 0.03 0.56 Mean dif. B 1.80 3.20 1.76 0.43 1.60 A 0.12 0.74 0.53 0.08 0.90 Mean % of
Improvement B 1.66 2.88 1.53 1.27 2.59 A 0.339 0.652 0.489 0.124 0.703 S.D B 0.909 1.973 1.195 0.654 1.254 A 0.087 0.168 0.126 0.032 0.181 S.E B 0.234 0.509 0.308 0.028 0.323 A 1.528 4.761 4.761 1.0312 3.127 “t” valve B 7.692 6.286 5.733 15.464 4.953 A < 0.2++ < 0.001** < 0.001** < 0.4++ < 0.01* “p” value B < 0.001** < 0.001** < 0.001** < 0.001** < 0.001**
Gp Total chol. HDL LDL Triglycerides A 190.41 36.56 126.36 137.54 Mean BT B 205.63 45.45 133.72 138.01 A 183.88 38.33 117.76 135.22 Mean AT B 182.63 48.28 108.79 132.72 A 6.53 -1.76 8.59 2.32 Mean dif. B 23.01 -2.83 24.26 5.29 A 3.42 % 4.81 % 6.8 % 1.58 % Mean % of
Improvement B 11.19 % 6.22 % 18.64 % 3.83 % A 4.619 1.144 5.826 1.394 S.D B 18.48 11.13 19.17 11.562 A 1.192 0.295 1.504 0.359 S.E B 4.771 2.87 4.949 2.985 A 5.474 5.966 5.712 6.462 “t” valve B 4.822 0.994 4.902 1.773 A < 0.001** < 0.001** < 0.001** < 0.001** “p” value B < 0.001** < 0.4++ < 0.001** <0.1++
it can be stated that Udvarthana had better action over lipid profile.
Discussion on patients:
Case – 1:
A female Hindu patient, aged 35 years, was suffering from increased
weight since 9 years. She had associated features of Athi Pipasa, Athi kshudha,
Swasa, Athi Nidra, and Srama. Family history reveals that her parents were
obese. There was no history of Hypertension, Diabetes mellitus and long-term
use of drugs. She was vegetarian and takes food 4 times in a day. She preferred
cold drinks and Madhura Amla yukta ahara. Subject also revealed that she was
habituated with Avyayama, Divaswapna, Sukha shayya, Chestadwesha and
Achintana. She used to sleep for more than 10 hours in a day. Her Prakruthi was
analyzed as Kapha Vataja with Medasara Lakshana. Her Agni status (poorva and
adyatana) was in pravaravastha. She was born and brought-up in Anupa-Jangala
and diseased in Anupa-Sadharana Desha.
Her B.P, pulse and other general features were within normal limits.
Patient frame was medium with height of 158 cm and 90 kg of weight with BMI
36.05 on the day of admission. She had been allocated to group A, where she
took Trivrith lehya on 1st day and passed 9 Vegas. From 2nd day, she started
dynamic exercise and physiotherapy along with prescribed diet chart. Her body
circumference and lipid profile values were taken before and after treatment.
On 9th day, changes were noticed in subjective parameters. There was
decrease of Total cholesterol by 3.3mg/dl, increase in HDL by 0.3 mg/dl, LDL
decreased by 3.1mg/dl, and decrease in Triglycerides by 2.7 mg/dl. She reduced
her body weight by 2 kg and BMI decreased by 0.08. There were no changes in
Discussion
Effect of Udvarthana in Sthoulya
121
Chest, Abdomen and Mid-arm circumference. But Hip and Mid-thigh
circumference were reduced by 1 cm.
Case – 2:
A female Hindu patient, aged 38 years, was suffering from increased
weight since 10 years with positive family history. She had associated features
of Athi Pipasa, Athi kshudha, Swasa, Athi Nidra, Athi Sweda and Srama. There
was no history of long-term drug use, Hypertension and Diabetes mellitus. She
used to take vegetarian diet for 4 times a day. She preferred fruit juice, cold
drinks and Madhura Amla yukta ahara. Subject also revealed that she was
habituated with Avyayama, Divaswapna, Sukha shayya, Chestadwesha and
Harshanitya. Her Prakruthi was analyzed as Kapha Pittaja with Medasara
Lakshana. Her Agni status (poorva and adhyatana) was in pravaravastha. She
was born, brought-up and diseased in Anupa-Jangala Desha.
Her B.P, pulse and other general features were normal. She was of
medium frame with height of 155 cm and 91 kg of weight with BMI 37.87 on
the day of admission. She had been allocated to group B, where she took
Trivruth lehya on 1st day and passed 7 Vegas. From 2nd day, she underwent
Udvarthana treatment with Triphaladi choorna followed by Sarvanga bashpa
sweda with Dashamoola kwatha. After 7 days of Udvarthana, she was given
Trivruth lehya on last day of her hospital stay. She passed 6 Vegas. Snigdhata
was noticed in stools after first 3 Vegas. The patient was on low-calorie diet and
performed prescribed dynamic exercises and physiotherapy. Her body
circumference and lipid profile values are taken before and after treatment.
On 9th day, changes were noticed in subjective parameters. There was
decrease of Total cholesterol by 11mg/dl, increase in HDL by 16mg/dl, LDL
decreased by 28 mg/dl, but there was increase in Triglycerides by 5 mg/dl. She
reduced her body weight by 5 kg and BMI showed reduction by 2.08. There was
decrease of 1cm in chest, abdomen and hip circumference. No changes were
seen in Mid-arm and Mid-thigh circumference.
Discussion
Effect of Udvarthana in Sthoulya
122
Discussion on survey:
A total number of 516 adult subjects were surveyed, who had attended the
OPD of SDMCA & hospital Hassan for first time. The system of Hospital is
maintained in such away that every new patient after getting their registration,
has to go to Screening room, from where they will be sent to different OPD with
respect to their complaints. But the old cases will not be in contact with
screening room on their follow up. Hence the investigator had decided to select
the screening room for his survey study.
The objective of the study was to assess the incidence rate of obesity in
patients attending the above-mentioned OPD irrespective of their complaints.
BMI parameter was selected to assess the obese patients (BMI> 25). Hence with
the help of measuring tape (in cms) and weighing machine the height and weight
were noted. Few other vital data age, sex, religion, life styles and diet were noted
which are helpful for analysis. The survey was done on 30 working days in
between 16th August to 21st of September of 2003. There were total of 193
obese out of 516 patients in the study. The following are the out come of the
study.
Discussion on Age:
Out of 516 patients, 168 patients were belonging to age group between
21-30 years and there was only 1 patient in the age group between 81-90. These
data show that the younger age group patients are more aware of their health
problems.
Out of 193 obese patients 67(34.84%) were belonging to the age group of
21-30.
As the population was more in that age group, hence the prevalence rate
of obesity was more in the same.
Discussion
Effect of Udvarthana in Sthoulya
123
Discussion on sex:
A total number of 287 (55.62%) males and 229(44.30%) females were
present in the population, out of which obese patient were 84(43.52%) males and
109(56.48%) females which reveals that females are more prevalent for obesity.
Discussion on religion:
Survey was done in Hindu dominated area; hence the number of Hindu
cases was more in the study. Out of 484 Hindu patients, 179(92.76%) were
obese.
Discussion on life style:
308 patients were habituated to sedentary life styles, out of which 136
patients (70.47%) had obesity. This shows that, sedentary type of life style have
definite role in the causation of disease.
Discussion on diet:
Out of 516 patients, 316(61.83%) were consuming mixed diet (including
regular and occasional non-veg diet). 53.37% of regular mixed diet (non-veg > 4
times a month) and 11.92% of irregular mixed diet (<4 times a month) suffered
from obesity. This shows that non-vegetarian diet is one of the triggering factors
for obesity, avoidance of which (except fish which contains omega 3 fatty acids)
is believed to decrease BMI.
Difficulties and limitation of the study:
The major problem with the investigator was to allocate the patients into
control group. As the study was conducted in an Ayurvedic Hospital, the obese
patients attended the OPD, expecting some Ayurvedic remedy for their problem,
but when they were asked to undergo purgation and Exercises along with diet
many patients agreed after proper convincement. Once they started realizing that
Discussion
Effect of Udvarthana in Sthoulya
124
their problem is due to sedentary life style with high calorie intake, they pleased
and actively participated in the study. However this problem was not
experienced in case of trail group patients, as many of the patients visit Hospital
requesting to undergo Udvarthana.
The second difficulty was monitoring the diet of patients. During their
stay at Hospital some how they managed with great enthusiasm, but when they
lost their weight and after discharge patients were again attracted by sweets and
such other obesity predisposing foods and activities. However, it was
investigators out of reach to observe each patient after discharge from Hospital.
Many of the obese patients were attracted towards the products, which are
experimented in abroad, were brought to India to exploit the innocent citizens.
Many of such products were telecasted right from local TV channels to
international channels. Almost all magazine will publish one or the other such
products showing before and after treatment photos. Some of the patients in the
study were undergone such products and met with adverse effects. It is the
responsible of the government to take strict action over such things and help the
public for avoiding such mistakes.
As the sample size was small, a pinpoint conclusion cannot be drawn.
Hence it is suggested to conduct the same study over large samples. The follow
up period was restricted for one month keeping in view of study period. In
future, the same study should be carried out to check the regain of weight for a
considerable period.
Further recommendation of study:
1. Same study on secondary obesity.
2. Continuation study with Yavamalaka choorna during follow-up.
3. Survey study in healthy population to assess its prevalence rate.
Conclusion-summary
Effect of Udvarthana in Sthoulya
125
The present study was carried out, giving importance to literary,
diagnostic and therapeutic aspect considering the ancient as well as
contemporary views. The following conclusion along with summary is drawn
after considering the clinical and conceptual study.
This study has done giving equal importance for conceptual as well as
clinical aspects. One should agree the fact that the modern medicine
advanced a lot in this aspect in terms of assessment for weight as well as fat
parameters. Inspite of that there are lacuna in some aspects like defining
obesity, its treatment etc.
The lipid in modern parlance is correlated to Medas with a thought that
Medaja upakrama can be adopted in treating lipid disorders. At the same time
a brief review regarding the lipids and Hyperlipidemia was done.
The Lakshana described in Ayurvedic literature are more worthwhile
than the disease features explained in contemporary science. Ayurveda gives
importance to the bulk of the body; hence to assess the same one should take
the help of Anguli pramanas so as to assess the normal size of the body and
to compare the same with increased bulk of diseased.
The drugs that are described as Pathya for sthoola are rich source of
fibers and hence they can be used, so that patient feels the fullness of
stomach. Fibers stimulates satiety center.
Classification done on nidana like Aharaja, Viharaja, Manasika and anya
holds good for sthoulya. Because each of them have its own role to play but
above all samanyaja stands first. If that is not in favour of sthoulya than
disease cannot manifest. Hence it can be concluded that it is the
Vikaravighatakara bhava.
Conclusion-summary
Effect of Udvarthana in Sthoulya
126
The degrees of obesity like mild, moderate and morbid can be correlated
with vagbhatacharya’s classification like Avara, Madhyama and Pravara Sthoola
respectively.
The concept behind explaining Sthoola as one among the Ashta Nindita is
mainly due to symptoms like Ayushohrasa, complicated pathology and long-
term management.
Among genetic and environmental factors, it is very difficult to judge, which
is having a key role in the manifestation. In the survey study, some of obese
cases reveal the family history and food that they consume, which are also
predisposing factors that are commonly observed. Hence it is difficult to separate
these two entities.
Exercise is having its own role to play in reducing and maintaining the
weight. These patients should be advised to stay active through out the day and
minimize some of the sedentary activities like watching television, using vehicle
etc. They always require continuous encouragement and motivation to perform
physical activities.
Udvarthana should be practiced as a daily regime especially for obese
patients. In classics, it is described to perform Udvarthana after vyayama and
before snana, but if it is done before vyayama then it will be helpful to utilize the
peripheral fatty acids for energy, there by increasing the lipolytic action.
Synonyms described in the text should be used as and when required instead
of using them in broader sense. For example to describe a person of mild obesity
the terms like Medasi, Medurata are suitable whereas to point out morbid obese
person using the term like athi sthoulya etc. by doing so it will be helpful to
choose the therapy with quality and quantity of Pathya merely by looking at the
diagnosed term.
Conclusion-summary
Effect of Udvarthana in Sthoulya
127
Some of the scholars make differential diagnosis of Sthoola person with the
patients of Sarvanga shotha and Udara, but thorough inspection itself
differentiates these conditions.
Sthoulya is not just a physical weight burden but the patient also faces many
psychological problems right from wearing tight cloths till insult in the society.
A clinical study was done on 30 patients. The patients were divided into
two groups namely group A and group B and were advised to follow exercise
and prescribed diet for 1 week, before to which they had been given purgation
with Trivruth lehya. This was common for both the groups. Apart from this
group B underwent Udvarthana and purgation after complication of Udvarthana.
Swedana was given after Udvarthana on every day. Lipid profile was done
before and after treatment. Other objective parameters like weight, BMI and
anthropometrics reading were considered. The associated features were also
graded and compared before and after treatment. The duration of the treatment
was 9 days and after that the patients were asked for follow up after one month.
The results (subjective and objective) were encouraging in trail group (B). The
observation and results were tabulated and statistically analyzed with relevant
parameters.
With respect to reduction in weight, group A patients shown 1.16 0.74
kg where as in group B 4.03 1.34 kg. Mean decrease of BMI was 0.47 0.29
and 1.63 0.65 of BMI in group A and B respectively.
The serum lipids had also responded well for the treatment. Total
cholesterol levels increased with an average of 6.53 and 23.01 mg/dl in A & B
groups respectively. There was mean increase of HDL by 1.76 and 2.83 mg/dl,
however in some cases the levels decreased in group B. LDL levels were
decreased by 8.6 and 24.93 mg/dl and Triglycerides also decreased by an
average of 2.18 and 5.29 mg/dl in group A and B respectively. Over all the
patients of Udvarthana group responded well compared to the subjects of control
group.
Conclusion-summary
Effect of Udvarthana in Sthoulya
128
The patients also showed marked difference in body circumferences
especially in abdominal circumference. Here also group B patients responded
well than control group subjects. There was a relative improvement in subjective
criteria in both groups. It can be concluded that Udvarthana is having significant
effect in Sthoulya.
To know the incidence rate of obesity, a survey was conducted and it is
discussed in observation chapter.
After completion of study, it can be concluded that environmental factors
plays an important role in the causation of the disease and a holistic approach is
required to tackle this multifactorial disease.
Approach to an obese patient:
History:
☻ Smoking habit
☻ Current drug therapies that affect weight
☻ Alcohol intake
☻ Risk factors like angina, stroke
Examination:
☻ BMI
☻ Waist circumference
☻ Blood pressure
Psychological:
☻ Depression
☻ Eating disorder
Investigation:
☻ Lipid profile
☻ Thyroid hormone analysis
☻ Blood glucose
Conclusion-summary
Effect of Udvarthana in Sthoulya
129
Principals of behavioral modification:
Issues to be discussed in-group behavioral therapy are:
Self-monitoring using a food diary
Need for long-term life style change
Need to modify eating habits
Need to assess present exercises level and ideas to increase this if
necessary
Importance of restricting occasions and situation when inappropriate
types or amounts of food are eaten
Separation of eating from other activates
Planning of daily food intake
Understanding of food levels and adopting recipes with regard to fat,
salt, sugar and fiber.
Possibility of changes to individual eating style
Identification of the causes of negative emotions and stress
Recognition that eating may be related to stress
Need to self-monitor feeling and emotions
Dealing with situations that interfere with every day food choices.
Effect of Udvarthana in Sthoulya
130
List of reference: Review of literature- Sthoulya:
1. Bh. Pr. Madhyama 39 2. Ch. su.21/19 3. Su. su 35/34 4. Sha. Madhyama 7/68 5. Ka. khila 6. Ch. chi 15/35 7. Bh. Pr 8. Su. su 15/7 9. Pratyaksha Shareera pg-10 10. Su. sha 4/12 11. Su. sha 9/12 12. Ch. chi 15/18 13. Ch. chi 15/17 14. Ch. vi 8/106 15. Su. su 35/16 16. Su .su 15/14 17. As. Hr. su 11/11 18. Su. su 15/9 19. As. Hr .su 11/18 20. Ch. su. 23/3-6 21. Ma. Ni 31/1-2 22. Su. su 15/32 23. Ch. vi 5/15-16 24. Ch. ni 4/5 25. Ch. chi 6/4 26. Ch. vi 3/ 27. Ch. ni 4/4 28. Ch. chi 28/9 29. Ch. chi 11/12 30. Ch. chi 22/18 31. Ch. su 28/15 32. Ch. ni 4/8 33. Su. sha 9/12 34. As. Hr. ni 1/2 35. Ma. Ni 1/5 36. Su. su 15/32 37. Ch. su 21/4 38. As. Hr. su 11/10-11 39. Ch. vi 5/ 40. As. Hr. su 41. Ch. chi 21/40 42. Ch. su 21/5 43. Ch. su 10/8 44. Ch. su 10/10-13 45. As. Hr. su 14/31 46. Ch. chi 6/57
Effect of Udvarthana in Sthoulya
131
47. Ch. su 23/8-13 48. Ch. su 21/16 49. Ch. su 21/15 50. Ch. su 21/10 51. Ch. su 25/40 52. Ch. su 21/17
Review of literature- Obesity:
1. Essentials of Medical Physiology- K Shambhulingam 2. Principles of Anatomy and Physiology- Tortora & Grabowski 3. Textbook of Physiology – Guyton 4. Textbook of Preventive and Social Medicine – K Park 5. Textbook of Preventive and Social Medicine – Gupta & Mahajan 6. Harrison’s Principles of Internal Medicine 7. Pathologic Basis of Disease- Robbins 8. Clinical Medicine – Kumar & Clark 9. Physical Diagnosis – Vakil & Golwalla 10. Principles of Community Medicine – Sridhar Rao. 11. Principle and Practice of Medicine – Davidson 12. Clinical Dietetics & Nutrition – Antia & Philip
Review of literature- Udvarthana:
1. Ch. su 22/14 1a. Ch. su 22/14: chakrapani 2. Ra. vai.30/14 3. Ch. su 22/34-35 4. Su. ut. 39/104 5. As. San. su 24/12 6. As. Hr. su.14/17 7. Ch. su 22/37 8. Ch. su 21/13-14 9. Su. ut 39/105 10. As. Hr. su 14/18 11. As. San. su 21/16 12. Ch. su 22/41 13. Ch .su 16/7-8 14. Yo. Ra. ritucharya 15. As. Hr. su 3/19 16. Su. chi 24/54-56: Dalhana
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Effect of Udvarthana in Sthoulya
132
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Annexure
Ef Effect of Udvarthana in Sthoulya
I
Department of Post-Graduate studies in Swasthavritta, SDM College of Ayurveda, Hospital, Hassan.
Clinical Trail: “Effect of Udvarthana in Sthoulya” Candidate: Dr.Prasanna Kumar.K M.D scholar
CASE SHEET PROFORMA FOR STHOULYA Name of the patient: Date: Age: O.P. No: Occupation: I.P. No: Sex: Group: Religion: Clinical trail No: Marital status Date of admission: Socio Economic: Date of discharge: Education: Result: Occupation: Address: Pradhana vedana and avadhi: Anubandha vedana:
General Instruction: If there is uncontrolled appetite in between meals then, carrot, cucumber,
mosambi, orange, sprouts can be taken in moderate quantity. Avoid sweets, oily foods, ghee, curds, potato, banana, mango and other foods
that contain more of carbohydrate. Avoid mutton, chicken, pork and other non-vegetarian foods except fish. Foods stuffs prepared of rice in moderate quantity. Avoid using coconut / ground nut oils and use refined oil for cooking. Avoid bakery items, chocolates, cold drinks, milk and milk products except
buttermilk, alcohol. Perform exercises atleast for 1 hour / day, brisk walk, jogging, Yogasana Avoid day sleep, TV watching and such other sedentary works.