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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 4-9

Management of Sthaulya through Tailapana and Virechana karma: A Case report


1 Panchakarma Unit, Lokbandhu Rajanarayan Combined Hospital, Lucknow, Uttar Pradesh, India
2 Department of Panchakarma, S.G.A.M., G.A.U., Jamnagar, Gujarat, India
3 Department of Panchakarma, I.P.G.T. & R.A., G.A.U., Jamnagar, Gujarat, India

Date of Submission03-Jul-2019
Date of Acceptance12-May-2020
Date of Web Publication14-Jul-2020

Correspondence Address:
Dr. Adil Rais
Lokbandhu Combined Hospital, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JACR.JACR_5_20

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  Abstract 


Obesity is one of the most challenging health issues in the present scenario, which has almost taken the shape of an epidemic and affected the developed as well as the developing nations across the globe. Obesity exposes an individuals' susceptibility to several diseases which may affect multiple systems. Acharya Charaka has quoted Ati-sthaulya under the eight varieties of impediments which are designated as Ashtau-nindita purusha. Ati-sthaulya is one among eight such morbidities. Modern medications available for obesity have not yet been established to be as effective as proper diet, and exercise still remains the mainstay of obesity management. Ayurveda, though incorporating Panchakarma treatment modalities, may be considered as an alternative for management of obesity and correction of Doshas, Dhatus, and Malas involved at the basic level. This work was aimed to study and evaluate the effect of Virechana karma (~purgation therapy) in the management of Sthaulya. A 33-year-old male obese patient was treated with Virechana karma after Deepana (~appetizers), Pachana (~digestives) followed by Snehapana (~internal administration of oleaginous substance) with Murchita taila. After the treatment, significant reduction was noticed in weight as well as in the anthropometric measurements. Significant changes were also observed in the biochemical markers such as lipid profile after Snehapana and after Virechana karma. No untoward effects with this therapy were observed during the treatment regimen.

Keywords: Obesity, Panchakarma, Sthaulya, Virechana karma


How to cite this article:
Rais A, Zala D, Mungra P, Keshari N, Thakar AB. Management of Sthaulya through Tailapana and Virechana karma: A Case report. J Ayurveda Case Rep 2020;3:4-9

How to cite this URL:
Rais A, Zala D, Mungra P, Keshari N, Thakar AB. Management of Sthaulya through Tailapana and Virechana karma: A Case report. J Ayurveda Case Rep [serial online] 2020 [cited 2020 Sep 19];3:4-9. Available from: http://www.ayucare.org/text.asp?2020/3/1/4/289376




  Introduction Top


Obesity refers to an excessive accumulation of fat in the body, resulting in impaired health. India saw a marked upsurge in obesity index from its 19th position for both men and women in 1975 – 5th and 3rd positions, respectively, in 2014,[1] reflecting increasing the prevalence of obesity. In the past ten years, the number of obese people has doubled in the country as per the National Family Health Survey-4 (NFHS-4).[2] Junk food, alcohol consumption, and sedentary life styles are leading to silent self-destruction, making one in every five Indian men and women either obese or overweight. The prevalence rate of obesity and central obesity in India varies from 11.8% to 31.3% and 16.9% to 36.3%, respectively.[3] Abdominal obesity is one of the major risk factors for cardiovascular disease. The incidence of chronic diseases such as diabetes mellitus and hypertension is also higher among obese individuals. As per the WHO, obesity has reached epidemic proportions globally, with more than one billion adults overweight and at least 300 million of them obese. The key causes are increased consumption of energy dense foods, high in saturated fats and sugars, and reduced physical activity.[4]

In Ayurveda, obesity has been described as Sthaulya or Medoroga in Santarpanottha vikara,[5] i.e., the disease caused by Ayathopachaya (~over nourishment). In case of an obese person, the site of metabolic disturbances is Medo dhatu and Medovaha strotas (~fat channels) are chiefly affected. Causes of Sthaulya may be of two types; exogenous causes comprise potentiating diet and lifestyle while endogenous causes include Dosha, Dhatu, and Mala and Srotasa as chiefly involved. Nidana (~causative factors) of Sthaulya can be broadly classified as Aharatmaka (~diet oriented), Viharatmaka (~due to faulty lifestyle), and Manasika (~psychological factors). Aharatmaka nidana mainly includes excess intake of Madhura and Snigdha ahara (~sweet and unctuous diet).[6] Acharya Charaka has placed Ati-sthaulya under the eight varieties of morbidities, which are mentioned as Ashtau-nindita purusha (~eight despicable persons); Ati-sthaulya comprises one of them.[7] Acharya has listed eight defects underlying Sthula Purusha,[8] i.e., Ayuhrasa (~shortening of lifespan), Javoparodha (~hampered movements), Alpa-vyavayita (~decreased sexual desire and indulgence), Daurbalya (~debility), Daurgandhya (~foul smell), Swedabadha (~profuse sweating), Ati-trisha (~excessive thirst), and Ati-kshudha (~ excessive hunger). Acharya Vagbhatta opines that derangement of Agni (~digestive power) leads to the production of Ama[9] (~ undigested or partially digested food), which disturbs Dhatwagni of fatty tissues and blocks proper formation of further tissues. Improperly formed fatty tissue accumulates in the body producing Sthaulya. Line of treatment for it is Apatarpana[10] (~depletion therapy) and Langhana (~which produce lightness in the body), which can be performed by both Shamana and Shodhana karma.


  Case Report Top


A 33 year old male patient came to the outpatient department, with complaints of gradually increasing body weight since past ten months. The Associated complaints presented by him were fatigue with minimal work and pain over the right side of the lower back region. The patient was diagnosed with diabetes mellitus 2.5 years back, for which he was taking Metformin 500 mg once daily. His history revealed that the patient had no history of hypertension, bronchial asthma or hypothyroidism. There was no positive family history of increased weight and obesity. Patients' diet predominantly comprised rice and potatoes and less of other green vegetables and fruits. There was no history of alcohol, tobacco, or drug addiction, but an over consumption of soft drinks (1–1.5 L of coke per day) and frequent and excessive use of chocolates were present. The patient was on Metformin (500 mg/day) for the past 2.5 years.

Ashtavidha[11] and Dashavidha pareeksha[12] along with general and systemic physical examinations with anthropometry of the patient were conducted. Investigations showed normal hematological and blood sugar reports, but changes were seen in the biochemical tests with special reference to lipid profile. Considering the clinical examinations, Body Mass Index (BMI) (>29.99 kg/m2), and laboratory investigation findings, the patient was diagnosed as Obese Class I.


  Treatment Protocol Top


Virechana karma after Deepana (~appetizers) and Pachana (~digestives) followed by Snehapana (~internal administration of Sneha-like oil or cow Ghee) was planned in this case. The details of the procedure are described below:

Purva karma (~Pre-operative procedure)

The patient was administered with two g each of Guduchi (Tinospora cordifolia Willd.), Haritaki (Terminalia chebula Retz.), and Shunthi (Zingiber officinale Roscoe) thrice a day before food for three consecutive days for Deepana and Pachana. After observing proper appetite and bowel movements, the patient was administered with Arohana shodhana purva snehapana (~gradually increased dose of Sneha) with Murchita taila[13] for four consecutive days with initial dosage of 50 ml and then increased to 100, 150, and 200 ml on 2nd, 3rd, and 4th day, respectively. After appearance of Samyak snigdha lakshana[14] (~symptoms of proper internal oleation) after 4th day of Snehapana, the patient was advised Sarvanga abhyanga (~whole-body massage) with Murchita taila and Swedana by Sarvanga bhashpa sveda (~whole-body fomentation with medicated vapors) for the next three days.[15] During these three days, light, warm, and liquid diet including green gram soup and rice was advised along with citrus fruits such as oranges. Thereafter, on the 8th day in the morning, Virechana karma was performed.

Pradhana karma (~Main procedure)

Before administration of Virechana yoga, Abhyanga with Murchita taila and Bashpa swedana has been given at morning on the day of Virechana. Vitals including temperature, pulse, and blood pressure were recorded at regular interval during the Pradhana karma. Following the classical instructions, Virechana yoga was administered after passage of Kapha kala,[16] i.e., about 10 am on empty stomach. Virechana yoga (~purgative formulation) was Trivrut lehya[17] 80 g, Katuki churna (~Picrorrhiza kurroa Royle ex Benth) 10 g, and Triphala kashaya 100 ml. The patient was advised to take warm water repeatedly at a gap of every 15–20 min to support proper purgation. After that, the patient was monitored carefully. Numbers of Mala vegas after administration of Virechana drug were counted. End point which is indicated by the symptoms of Samyak virechana[18] (~proper symptoms of medicated purgation as per classics) was seen in the patient, which include cessation of purgation on its own, feeling of lightness in body, improved appetite, feeling of well-being, and mild weakness. The end point indicator includes the Kaphanta (~presence of mucous) along with stools in the last one or two Vegas. He was administered normal water once the symptoms of proper Virechana appeared to cease more bowel evacuations.

Pashchata karma(~Post-operative procedure)

No untoward effects were seen during the Virechana karma. On the basis of Madhyama vegiki shuddhi (~ moderate number of bowel evacuations), the patient was advised specific dietary regimen accordingly for five days, i.e., Samsarjana karma.[19] This included Peya (~watery gruel prepared from Barley) for first two diets, followed by Yavasaktu (~semi-liquid gruel prepared from barley), Yusha (~soup prepared from green gram), and Mamsarasa (~Mutton soup) for subsequent two diets each, respectively. Barley was used owing to the history of diabetes in the patient. Normal diet was restored with proper Pathya (~advisable food items and lifestyle) and Apathya (~food items and lifestyle to be avoided).


  Followup and Outcome Top


After Deepana-Pachana, appetite was relatively better, improved bowel movements, and proper evacuation was reported by the patient. A decrease in body weight from 104 to 101 kg and BMI from 30.39 to 29.51 kg/m2 was observed after completion of Shodhananga Snehapana (~internal oleation), i.e., there was a relative feeling of lightness in abdomen and improved appetite and sleep after Snehapana [Table 1]. On measuring, reduction in the mid arm circumference, mid leg circumference, circumference of thigh, and abdominal girth was noticed [Table 2]. There was a reduction in total lipid content, cholesterol levels, Very Low Density Lipoproteins (VLDL). However, an increase in the levels of High Density Lipoproteins (HDL) and Low Density Lipoproteins (LDL) was noticed after Snehapana [Graph 1].
Table 1: Weight and body mass index

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Table 2: Anthropometry

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After Virechana, further decrease in body weight to 99 kg and BMI to 28.93 kg/m2 was observed; abdominal lightness and increased appetite were reported by the patient [Table 1]. On palpation, abdomen was soft and no significant weakness was reported by the patient. Anthropometric measurements suggested of decreased body weight and reduction in the mid arm circumference, mid leg circumference, circumference of thigh, and abdominal girth [Table 2]. There was a reduction in total lipid content, cholesterol levels, and VLDL. However, an increase in the levels of HDL and LDL was noticed after Virechana. Blood sugar levels were within normal limits before and after the treatment [Graph 1]. Further decrease in body weight to 98 kg and BMI to 28.63 kg/m2 was seen after completion of Samsarjana karma [Table 1].

The patient was advised to discontinue anti-diabetic drug he has been taking, on the day of Virechana and during Samsarjana karma owing to his normal blood sugar levels before treatment. After completion of the treatment and during follow-up also, his blood sugar levels were within normal limits due to which he did not take any further medication up to a month. However, he was advised to consult his diabetologist and regularly monitor his blood sugar profiles.

On discharge, the patient was advised to take combination of Triphala (2 g), Guduchi (2 g), Vidanga (1 g), Yashtimadhu (1 g), and Katuki (500 mg) in powdered forms twice daily with warm water before meals. This drug regimen was planned for one month, and specific diet was advised to the patient which included more use of fibrous diet, green and leafy vegetables, and unrefined food substances along with the consumption of warm water and routine brisk walking, which has to be gradually increased and maintained as per the caliber of the patient.


  Discussion Top


Considerable improvement was present in weight [Table 1] and anthropometric measurements [Table 2] along with the biochemical markers [Graph 1], which were assessed regularly. Body is first prepared with Deepana-Pachana, Snehapana, and Swedana, for proper saturation of Doshas thereafter their elimination through Shodhana at proper time through nearest possible route according to the strength of the patient. Deepana and Pachana do kindling of Agni and digestion of Ama, respectively. Sneha will not undergo proper digestion if Agni is not normal, which may lead to various complications.

Snehapana is the most important Purva karma for Vamana and Virechana. The properties of Sneha dravya s are Sukshma (~minute), Sara (~non stable), Snigdha (~unctuous), Drava (~liquid), Picchila (~slimy), Guru (~heavy), Shita (~cold), Manda (~dull), and Mridu[20] (~soft). Charaka explains that administration of Sneha helps in bringing the Dosha from Shakha to Kohstha (~abdominal cavity) for the expulsion by Vriddhi (~excessive increase of Dosha), Vishyandana (~liquefaction of Dosha), Paka (~digestion of Dosha), Srotomukha vishodhana (~cleansing of channels), and Vayoscha Nigraha[21] (~downward movement of Vata). It is carried for 3–7 days based on the digestive capacity of the patient, and symptoms of proper saturation with Sneha which are Vatanulomana (~regulation of flatus), Deeptagni (~improvement in digestion), Snigdhavarcha (~unctuous stools), Snigdhagatra (~unctuousness on skin), and Mardavata (~softness in the body) appear. These were the symptoms seen in the patient which are the end point indicators to cease Snehapana, subsequently followed by Abhyanga and Swedana for three days.

Tila taila (Sesame oil) is subjected to Murchana[22] by boiling with the Kalka (~paste) of Triphala (Haritaki, Amalaki, and Bibhitaki), Manjishtha (Rubia cordifolia L.), Haridra (Curcuma longa Linn.), Lodhra (Symplocos racemosa Roxb.), and Musta (Cyperus rotundus Linn.). Taila murchana process helps to improve color, aroma, and overall qualities of the oil and makes it palatable and facilitates easier digestion by removal of Ama dosha of Tila taila.

Tila taila is best Sneha dravya among the oils of plant sources.[23]Taila is used widely for internal and external conditions. It alleviates Vata but, at the same time, does not aggravate Kapha.[24] From therapeutic point of view, Taila when treated with other drugs easily imbibes the properties of those drugs. Vagbhatta explains the importance of Tila taila as the oil that makes lean persons fat and fatty people leaner.[25] In obese people, by its Sukshma, Teekshna, and Ushna properties, it enters finer channels, does Kshapana karya (~selective drying or abatement of fatty tissue) for Meda. Therefore, Murchita tila taila was selected for Snehapana, and it was given for four days in gradually increased dosage because if the Sneha is administered in a constant dose, the body becomes habitual for Sneha and will not produce Utklesha (~vitiation) of Dosha which is an essential requirement before elimination through Shodhana.

On the 5th day, when symptoms of proper internal oleation appeared, the patient was subjected to Abhyanga (~external oleation) and Swedana (~sudation therapy). Abhyanga produces Mardavta, i.e., softens the morbid humors and localizes them. Swedana is done to liquefy the vitiated Doshas which are spread throughout the body.[26] Subsequent Swedana also channelizes the Doshas into Koshtha from Shakha (~peripheral organs) by causing vasodilatation and thereby increasing the vascularity. Thereafter, the increased Doshas are expelled out through Pradhana karmas (~main therapeutic Panchakarma procedures) such as Vamana and Virechana. Charaka has mentioned that Swedana karma is the best treatment for vitiated Vata and Kapha dominant diseases.[27]Virechana karma was also selected in this study as the patient was diabetic and Charaka has advised Shodhana for Sthula pramehi (~obese diabetic) and Brumhana for Krisha pramehi (~weak diabetic).[28]

As Snehapana and Swedana are performed before Virechana, the Doshas smear easily without any hindrance and easily come to the Amashaya and Pakvashaya (~upper and lower gastrointestinal tract) from where they are subsequently evacuated through Virechana. After the administration of Virechana drugs, 14 Vegas were observed which can be considered as Madhyama type of Shuddhi (~moderate purification).

Virechana drugs have the properties such as Ushna, Tikshna, Sukshma, Vyavayi, and Vikasi. Due to its Vyavayi guna, it can quickly circulate into the smaller capillaries of the body. Because of its Vikasi guna, it detaches the Malas from Dhatus. By virtue of its Ushna and Tikshna properties, the accumulated Doshas get liquefied and disintegrated at cellular level. Due to Sukshma guna and Anupravan nature, the Malas and excessive Doshas are ultimately drained towards Amashaya through vascular supply without obstruction. Virechana dravyas are predominantly composed of Prithvi and Jala mahabhuta[29] due to which they preferably act along with gravity and expel the vitiated Doshas primarily via the rectal route.

Samsarjana karma is the specific dietary regimen which is advised after performing Shodhana. Here, Peya prepared from Yava (~barley) was administered and Yavasaktu was given in place of Vilepi, as the person was diabetic and Santarpana should be given in Samsarjana karma to the diabetic patient. It plays an important role in protecting and improving Agni (~digestive fire) gradually. Due to elimination of excessive Doshas from the body after Samshodhana, Agni becomes weaker. To restore the strength of Agni and Prana,[30] the specific dietary pattern ensures normalcy of health and more robust Agni in a gradual manner.

Oral regimen in the study comprised of drugs which had Lekhaniya properties thereby aimed to maintain the weight attained after Shodhana. Triphala, Guduchi, Yashtimadhu, and Katuki[31] were used owing to their specific role in regulating metabolism in a better manner, i.e., lower the anabolic activity, and thereby controlling obesity. Besides, specific dietary regimen was planned for the patient, which included a well-balanced diet comprising more proteins, vitamins, and minerals and lesser carbohydrates and saturated fats, to which he was more used to, earlier. Regular exercise, meditation, brisk walking or jogging along with following normal biological clock such as early meals, early sleep, and early awakening were advised to be followed religiously. He was advised to properly chew the food. Day sleeping, overeating, consuming junk food and food items prepared from refined products such as Maida (~fine flour), confectionery items, alcohol, curd, sugar, and refined oils were also prohibited. He was also advised to refrain from chocolates and soft drink usage to which he was much used to, earlier.


  Conclusion Top


Marked change was noticed in the overall condition of the patient after Virechana. This change was not only limited to the gross appearance or anthropometric measures but also involved the biochemical markers like lipid profile of the patient. After the noteworthy changes brought about by Virechana, the patient was administered drugs to maintain the benefits produced and was advised proper lifestyle to put a check on increasing weight and simultaneously inculcate proper metabolism by burning calories continuously to remain in shape. This was a single case report which was noteworthy for the changes brought after Virechana in such patients. However, larger sample size shall be more valuable in drawing concrete conclusions.

Declaration of patient consent

Authors certify that they have obtained patient consent form, where the patient/caregiver has given his/her consent for reporting the case along with the images and other clinical information in the journal. The patient/caregiver understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  In this article
Abstract
Introduction
Case Report
Treatment Protocol
Followup and Outcome
Discussion
Conclusion
References
Article Tables

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