Changes

   

   

In biomedical science, the above-described eight types of undesirable persons are comparable to a variety of genetic and neuroendocrine disorders. Out of these eight types, the last two (atisthula and atikrisha) need therapeutic interventions and deserve special attention. According to Chakrapanі, physical deformities such as kubja (hunchback) and pangu (limp gait) may also be taken as undesirable.   

In biomedical science, the above-described eight types of undesirable persons are comparable to a variety of genetic and neuroendocrine disorders. Out of these eight types, the last two (atisthula and atikrisha) need therapeutic interventions and deserve special attention. According to Chakrapanі, physical deformities such as kubja (hunchback) and pangu (limp gait) may also be taken as undesirable.   

Too Obese: (Verse 3-4)

 

1. In the context of atisthula and atikrisha, Charaka has explored these conditions from the standpoint of their diathesis, clinical presentation, and management, which is comparable to approaches taken today to the study of obesity and leanness. Suśruta has considered rasa dhatu as the main culprit for both obesity and emaciation (rasa nimittameva sthaulyam karshyam ca).   Lipid precursors are acted upon by fat-specific energy (medhodhatvagni) for their conversion into adipose tissue (medodhatu). Vitiation of kapha dosha and excessive accumulation of fat-specific energy and waste products of adipose tissues (kleda) lead to dysfunction of adipose tissues. Adipose channels have two origins - kidney, adrenal and fat around them and other are visceral and omental fat (vapavahana).  These channels draw nutrition, including lipid from the antecedent flesh and transient lipid and then convert them into a stored form of lipid. As per biomedical science, obesity is associated with increased adipose stores in the subcutaneous tissues, skeletal muscles and internal organs such as kidney, heart, liver and omentum. Adipose tissues (medodhatu) form a crucial link to the concept of tissue metabolism. Low levels of fat-specific energy (medodhatvagni), despite a normal food intake, can lead to a steady accumulation of fat and the outcome is obesity.   The conventional system of medicine has given due consideration to certain factors such as insufficient sleep, genetic predisposition, later age pregnancy, certain medications and other epigenetic factors in the etiopathogenesis of obesity and its related disorders   .  

==== Too Obese (Verse 3-4) ====

Increased desire to eat among the obese (verse 4 )

 

In the context of atisthula and atikrisha, Charaka has explored these conditions from the standpoint of their diathesis, clinical presentation, and management, which is comparable to approaches taken today to the study of obesity and leanness. Suśruta has considered rasa dhatu as the main culprit for both obesity and emaciation (rasa nimittameva sthaulyam karshyam ca).  

 

Lipid precursors are acted upon by fat-specific energy (medhodhatvagni) for their conversion into adipose tissue (medodhatu). Vitiation of kapha dosha and excessive accumulation of fat-specific energy and waste products of adipose tissues (kleda) lead to dysfunction of adipose tissues. Adipose channels have two origins - kidney, adrenal and fat around them and other are visceral and omental fat (vapavahana).  These channels draw nutrition, including lipid from the antecedent flesh and transient lipid and then convert them into a stored form of lipid. As per biomedical science, obesity is associated with increased adipose stores in the subcutaneous tissues, skeletal muscles and internal organs such as kidney, heart, liver and omentum. Adipose tissues (medodhatu) form a crucial link to the concept of tissue metabolism. Low levels of fat-specific energy (medodhatvagni), despite a normal food intake, can lead to a steady accumulation of fat and the outcome is obesity. The conventional system of medicine has given due consideration to certain factors such as insufficient sleep, genetic predisposition, later age pregnancy, certain medications and other epigenetic factors in the etiopathogenesis of obesity and its related disorders.

 

==== Increased desire to eat among the obese (verse 4) ====

 

Charaka correlated an increased desire to eat with increased agni in the morbidly obese. Recent evidence suggests that leptin and ghrelin had shown their influence on appetite. In this context, ghrelin is produced from the stomach, and leptin is produced by the adipose tissue of fat storage reserves in the body, which is responsible for short-term and long-term appetite control respectively in the body.  In the brain melanocortin pathway has drawn the attention of research scholars that this pathway has a specific role in stimulating appetite, which is located in the area of the lateral and ventromedial hypothalamus and arcuate nucleus. These areas are directly related to the feeding and satiety centers .  

Charaka correlated an increased desire to eat with increased agni in the morbidly obese. Recent evidence suggests that leptin and ghrelin had shown their influence on appetite. In this context, ghrelin is produced from the stomach, and leptin is produced by the adipose tissue of fat storage reserves in the body, which is responsible for short-term and long-term appetite control respectively in the body.  In the brain melanocortin pathway has drawn the attention of research scholars that this pathway has a specific role in stimulating appetite, which is located in the area of the lateral and ventromedial hypothalamus and arcuate nucleus. These areas are directly related to the feeding and satiety centers .  

There are two distinct groups of neurons in the arcuate nucleus viz- The first group contains neuropeptide Y (NPY) and agouti-related peptide (AgRP) and the second group contains Pro-opiomelanocortin (POMC) and cocaine and amphetamine regulated transcript (CART). The first group of neuron i.e. NPY/AgRP exerts stimulatory inputs to the LH while inhibitory inputs to the VMH, which stimulate feeding and inhibit satiety respectively. Both groups of arcuate nucleus neurons are the under the regulation of leptin, which inhibits the NPY/AgRP group of neurons and stimulating the POMC/CART group of neurons. Hence, the leptin deficiency or leptin resistance leads to develop overfeeding tendency, which is caused by some genetic and acquired forms of obesity.     These findings suggest the genetic inputs in overweight and obesity, which is quite comparable to the Ayurvedic lexicons.   

 

Consequences of obesity (verse 5-8)

There are two distinct groups of neurons in the arcuate nucleus viz- The first group contains neuropeptide Y (NPY) and agouti-related peptide (AgRP) and the second group contains Pro-opiomelanocortin (POMC) and cocaine and amphetamine regulated transcript (CART). The first group of neuron i.e. NPY/AgRP exerts stimulatory inputs to the LH while inhibitory inputs to the VMH, which stimulate feeding and inhibit satiety respectively. Both groups of arcuate nucleus neurons are the under the regulation of leptin, which inhibits the NPY/AgRP group of neurons and stimulating the POMC/CART group of neurons. Hence, the leptin deficiency or leptin resistance leads to develop overfeeding tendency, which is caused by some genetic and acquired forms of obesity. These findings suggest the genetic inputs in overweight and obesity, which is quite comparable to the Ayurvedic lexicons.   

Serious diseases (daruna vikara) are the outcome of excessive obesity due obstruction of body channels by the Medas. This indicates ancient wisdom of Ayurveda acharyas, which is comparable to the impact of obesity on health perspectives of biomedical science .  We have yet to understand what they had foreseen in reference to fat accumulation around the kidneys. Decreased life span (ayukshaya) is stated to be an important consequence of obesity in Ayurveda. According to contemporary science, metabolic and psychological pathologies are often present together and are associated with dysregulation of the hypothalamic-pituitary-adrenal axis.  Affect disorders are also reported among obese binge eaters. The National Institute of Health, USA has issued an alert labeling obesity a "Killer disease" due to its health-related consequences such as  coronary disease, diabetes mellitus, hypertension, hyperlipidemia, kidney disorders, gallbladder disorders, cancer of colon, pancreas, breast, uterus, kidney and gallbladder, osteoarthritis, menstrual irregularities in females, cryptogenic cirrhosis of the liver and hepatocellular carcinoma, insulin resistance, and physiological hyperinsulinemia. Some of the social consequences of obesity could include divorces, due in part to reduce sexual activities between partners. Besides there, transitional physiological phases such as weight gain during adolescence in boys and girls, post-natal weight gain in women, and peri-post menopausal obesity are frequently noted in clinical settings that warrant special care and management              .   

 

Etiology, features, and consequences of atikrisha (emaciation)  

==== Consequences of obesity (verse 5-8) ====

 

Serious diseases (daruna vikara) are the outcome of excessive obesity due obstruction of body channels by the Medas. This indicates ancient wisdom of Ayurveda acharyas, which is comparable to the impact of obesity on health perspectives of biomedical science .  We have yet to understand what they had foreseen in reference to fat accumulation around the kidneys. Decreased life span (ayukshaya) is stated to be an important consequence of obesity in Ayurveda. According to contemporary science, metabolic and psychological pathologies are often present together and are associated with dysregulation of the hypothalamic-pituitary-adrenal axis.  Affect disorders are also reported among obese binge eaters. The National Institute of Health, USA has issued an alert labeling obesity a "Killer disease" due to its health-related consequences such as  coronary disease, diabetes mellitus, hypertension, hyperlipidemia, kidney disorders, gallbladder disorders, cancer of colon, pancreas, breast, uterus, kidney and gallbladder, osteoarthritis, menstrual irregularities in females, cryptogenic cirrhosis of the liver and hepatocellular carcinoma, insulin resistance, and physiological hyperinsulinemia. Some of the social consequences of obesity could include divorces, due in part to reduce sexual activities between partners. Besides there, transitional physiological phases such as weight gain during adolescence in boys and girls, post-natal weight gain in women, and peri-post menopausal obesity are frequently noted in clinical settings that warrant special care and management  

             .   

==== Etiology, features, and consequences of atikrisha (emaciation) ====

 

The etiological factors for atikrisha may be divided into two groups - excessive expenditure of calories and fewer intakes of calories. Either of these conditions leads to under-nutrition which ultimately results in atikrisha. In the pathogenesis of krishata, Vayu plays an important role. Most of the etiological factors observed in the case of krisha and atikrisha provoke vata vitiation. Thus, vitiated vata may be considered the most important factor in the pathogenesis of krisha. In sthaulya there is excessive formation and under-utilization (due to sedentary habit) of the rasa dhatu. On the other hand, in krishata there is less formation of rasa due to diseases or due to undernourishment. Further, Charaka and Suśruta both have categorized krishata as a rasa pradoshaja vyadhi (C.Su.28:10, Su.Su.15:37,24:8). In this way, rasa dhatu dushti mainly in the form of kshaya is found in extremely lean or emaciated people. The other dhatu involved in the pathogenesis of obesity as well as atikrisha is Meda since it is mentioned that  medokshaya (or the deficiency of meda) cause krisanga (A.H.Su.11:18).   

The etiological factors for atikrisha may be divided into two groups - excessive expenditure of calories and fewer intakes of calories. Either of these conditions leads to under-nutrition which ultimately results in atikrisha. In the pathogenesis of krishata, Vayu plays an important role. Most of the etiological factors observed in the case of krisha and atikrisha provoke vata vitiation. Thus, vitiated vata may be considered the most important factor in the pathogenesis of krisha. In sthaulya there is excessive formation and under-utilization (due to sedentary habit) of the rasa dhatu. On the other hand, in krishata there is less formation of rasa due to diseases or due to undernourishment. Further, Charaka and Suśruta both have categorized krishata as a rasa pradoshaja vyadhi (C.Su.28:10, Su.Su.15:37,24:8). In this way, rasa dhatu dushti mainly in the form of kshaya is found in extremely lean or emaciated people. The other dhatu involved in the pathogenesis of obesity as well as atikrisha is Meda since it is mentioned that  medokshaya (or the deficiency of meda) cause krisanga (A.H.Su.11:18).   

In biomedical terms, emaciation is the outcome of loss of the fatty contents or loss of adipose tissue component of subcutaneous fat, which is lying beneath the outer covering of the body. It is also known as extreme weight loss, leanness, or thinness.  In general term, it is also known as wasting, which is caused by hampered nutritional requirement at the tissue level and excessive starvation. Wasting or leanness is an important symptom of improper nourishment, which is commonly seen in various clinical conditions such as poverty, a variety of gastrointestinal disorders, various eating disorders, prolonged fever, malignant diseases, endocrine disorders, chronic infections, autoimmune disorders as well as parasitic infections.  The malnourished person faced a lot of problems related to cardiovascular, integumentary and urogenital systems. Disturbances in blood circulation, serum electrolyte, and serum protein are commonly observed in emaciated person. Such type individuals are more to suffer from infections due to deranged immune power and swelling in general.   

In biomedical terms, emaciation is the outcome of loss of the fatty contents or loss of adipose tissue component of subcutaneous fat, which is lying beneath the outer covering of the body. It is also known as extreme weight loss, leanness, or thinness.  In general term, it is also known as wasting, which is caused by hampered nutritional requirement at the tissue level and excessive starvation. Wasting or leanness is an important symptom of improper nourishment, which is commonly seen in various clinical conditions such as poverty, a variety of gastrointestinal disorders, various eating disorders, prolonged fever, malignant diseases, endocrine disorders, chronic infections, autoimmune disorders as well as parasitic infections.  The malnourished person faced a lot of problems related to cardiovascular, integumentary and urogenital systems. Disturbances in blood circulation, serum electrolyte, and serum protein are commonly observed in emaciated person. Such type individuals are more to suffer from infections due to deranged immune power and swelling in general.   

Obesity and leanness can manifest themselves in very severe and excessive forms than discussed here and those cases could make the management of such disorders - and any disease it could lead to – very challenging. While the principles of treatment remain unchanged, the therapeutic measures should be suitably intensified to counter the numerous disorders that arise because of excessive obesity and leanness (C.Su. 23/3-34). The patients of atikrisha and sthaulya perpetually suffer from diseases but the standpoint of treatment, the former is significantly more manageable because sthula (or the obese) suffers more in comparison to atikrisha (the emaciated) (Su.Su. 15:42). Further, it is mentioned that atikṛisha is a grave disease, but is considered better than atisthula from treatment aspect because there is no treatment for sthaulya. For proper treatment of sthulya the drugs must have Medohara, Agnihara and Vatahara action at the same time, which is neither possible from karshaṇa nor brimhana. Recent evidence also suggests that Charaka had associated extreme weight-loss/undernourishment with high rates of morbidity and mortality, although to a lesser extent than obesity    .     

Obesity and leanness can manifest themselves in very severe and excessive forms than discussed here and those cases could make the management of such disorders - and any disease it could lead to – very challenging. While the principles of treatment remain unchanged, the therapeutic measures should be suitably intensified to counter the numerous disorders that arise because of excessive obesity and leanness (C.Su. 23/3-34). The patients of atikrisha and sthaulya perpetually suffer from diseases but the standpoint of treatment, the former is significantly more manageable because sthula (or the obese) suffers more in comparison to atikrisha (the emaciated) (Su.Su. 15:42). Further, it is mentioned that atikṛisha is a grave disease, but is considered better than atisthula from treatment aspect because there is no treatment for sthaulya. For proper treatment of sthulya the drugs must have Medohara, Agnihara and Vatahara action at the same time, which is neither possible from karshaṇa nor brimhana. Recent evidence also suggests that Charaka had associated extreme weight-loss/undernourishment with high rates of morbidity and mortality, although to a lesser extent than obesity. 

Management of the Morbidly Obese (20-28)

    

==== Management of the Morbidly Obese (20-28) ====

 

In the conventional system of medicine, the main treatment for obesity consists of diet and physical exercise for short-term weight control. Maintaining the weight by short-term dietary control is very difficult to an obese person, and it required guided exercise and low calory diet in their daily regimens. Because lack of physical exercise is the key factor and imparts a role in the diathesis of obesity. 61 The lack of physical activities also plays an important role in obesity-associated with the involvement of brain and abdominal. Regarding physical exercise, it not only reduces body weight but also counteract metabolic adaptation but regulating nutritional balance set point.64 It is presumed that physical inactivity contributes to both visceral adiposity and cerebellar brain changes because in the area of cerebellar cortex and hippocampal dentate gyrus  of brain show enhanced synaptogenesis and neurogenesis in response to physical exercise training. [48,49,50]   

In the conventional system of medicine, the main treatment for obesity consists of diet and physical exercise for short-term weight control. Maintaining the weight by short-term dietary control is very difficult to an obese person, and it required guided exercise and low calory diet in their daily regimens. Because lack of physical exercise is the key factor and imparts a role in the diathesis of obesity. 61 The lack of physical activities also plays an important role in obesity-associated with the involvement of brain and abdominal. Regarding physical exercise, it not only reduces body weight but also counteract metabolic adaptation but regulating nutritional balance set point.64 It is presumed that physical inactivity contributes to both visceral adiposity and cerebellar brain changes because in the area of cerebellar cortex and hippocampal dentate gyrus  of brain show enhanced synaptogenesis and neurogenesis in response to physical exercise training. [48,49,50]   

In this context, Ayurveda has laid down a strong emphasis on drugs, dietary and lifestyle interventions for the management of atisthaulya.  Therefore, factors such as madhura, sheeta, snigdha, guru, picchila and lifestyle errors are to be avoided in such cases. Ruksha udvartanas are advocated obese patients as an external purificatory measure, while vamana, virechana, and asthapana basti as internal bio-purificatory measures. If an atisthula person possesses good stamina and strength, they should be treated with vamana and virechana karma. Non-unctuous, warm and strong enema are advocated such type of patients. [51,52,53,54] Yogic practices have a significant impact on the physical, mental, emotional and spiritual health of the individual. It is reported that a significant improvement in the levels of BP, LDL cholesterol, and BMI can be noted after three months of residential therapy consisting of vegetarian diet and kriya yoga. A randomized controlled study reveals that practicing yoga for a year brought about significant improvement in body weight and body density. Regular practice of yoga has shown to improve the serum lipid profile in patients (with known IHD) as well as in healthy subjects. A regular regimen of Praṇayama reduces stress hormone and levels of endorphin and enkephalin, consequently increasing the level of HDL while decreasing the level of LDL, VLDL and TGs. [55,56,57,58]   

In this context, Ayurveda has laid down a strong emphasis on drugs, dietary and lifestyle interventions for the management of atisthaulya.  Therefore, factors such as madhura, sheeta, snigdha, guru, picchila and lifestyle errors are to be avoided in such cases. Ruksha udvartanas are advocated obese patients as an external purificatory measure, while vamana, virechana, and asthapana basti as internal bio-purificatory measures. If an atisthula person possesses good stamina and strength, they should be treated with vamana and virechana karma. Non-unctuous, warm and strong enema are advocated such type of patients. [51,52,53,54] Yogic practices have a significant impact on the physical, mental, emotional and spiritual health of the individual. It is reported that a significant improvement in the levels of BP, LDL cholesterol, and BMI can be noted after three months of residential therapy consisting of vegetarian diet and kriya yoga. A randomized controlled study reveals that practicing yoga for a year brought about significant improvement in body weight and body density. Regular practice of yoga has shown to improve the serum lipid profile in patients (with known IHD) as well as in healthy subjects. A regular regimen of Praṇayama reduces stress hormone and levels of endorphin and enkephalin, consequently increasing the level of HDL while decreasing the level of LDL, VLDL and TGs. [55,56,57,58]   

Recent evidence suggests that some ayurvedic herbal drugs are found to be very effective in normalizing deranged lipid profiles, reducing BMI and slowing down the risk heart diseases. Ayurvedic drugs such as Rasona (Allium cepa), Guggulu (Commiphora mukul),  Puṣhkaramula (Inula racemosa), Arjuna (Terminalia Arjuna), Dhānyaka (Coriandrum sativum), Nishamalaki churṇa (powder of Emblica officinalis and Curcuma longa),  Haritaki (Terminalia chebula), Haridra (Curcuma longa), Bilva (Aegle marmelos), Tejapatra (Cinnamomum tamala), Vrikshamla (Garcinia cambogia) and Ayurvedic formulations such as- triphala guggulu, medohara guggulu, amṛitadi guggulu, arogyavardhani vaṭi etc. are also found to be  effective in weight reduction as well as relief in other signs and symptoms. [1,2,3, 59.60,61,62, 63,64, 65, 66,67,68, 69]  

Recent evidence suggests that some ayurvedic herbal drugs are found to be very effective in normalizing deranged lipid profiles, reducing BMI and slowing down the risk heart diseases. Ayurvedic drugs such as Rasona (Allium cepa), Guggulu (Commiphora mukul),  Puṣhkaramula (Inula racemosa), Arjuna (Terminalia Arjuna), Dhānyaka (Coriandrum sativum), Nishamalaki churṇa (powder of Emblica officinalis and Curcuma longa),  Haritaki (Terminalia chebula), Haridra (Curcuma longa), Bilva (Aegle marmelos), Tejapatra (Cinnamomum tamala), Vrikshamla (Garcinia cambogia) and Ayurvedic formulations such as- triphala guggulu, medohara guggulu, amṛitadi guggulu, arogyavardhani vaṭi etc. are also found to be  effective in weight reduction as well as relief in other signs and symptoms. [1,2,3, 59.60,61,62, 63,64, 65, 66,67,68, 69]  

Management of the emaciated/too lean (verse 29-34)

 

==== Management of the emaciated/too lean (verse 29-34) ====

 

Too Lean patients are brought to good health through renourishment or reintroducing nourishing liquids and food to the body and check the process of catabolism. It starts with a glass of water followed by mixed with lemon and table salt and finally reach to juices, which is made up of vegetable, pulses, rice mixed with pepper, lemon juice and table salt. Later on, it is replaced with cow milk, soups of pulses and vegetable mixed with butter and salt.  If the emaciated status is improved, try to introduced small amount of solid food in meals at the frequent interval and try to avoid a large amount of solid food at a time. The dietary regimen is to be focused on proteins, fats, carbohydrates, multi-vitamin and mineral for the management of the emaciated person. It is always kept in mind at the time of management of the too lean person, excessive fatty foods items and excess fiber dominated grains and vegetable are to be avoided because they are deficient in energy and consume too much time for digestion.  Treatment of emaciation also includes prescribing a lot of sleep, rest, relaxation, and counseling. In the present context, Rasa means body fluid which is responsible for the nourishment of entire body and mind. Impairment of circulation of body fluid results in diseases and decay. Rasa should be available in adequate quantity and quality for it to circulate through the cells of the body, providing the requisite nourishment they need for proper functioning.  

Too Lean patients are brought to good health through renourishment or reintroducing nourishing liquids and food to the body and check the process of catabolism. It starts with a glass of water followed by mixed with lemon and table salt and finally reach to juices, which is made up of vegetable, pulses, rice mixed with pepper, lemon juice and table salt. Later on, it is replaced with cow milk, soups of pulses and vegetable mixed with butter and salt.  If the emaciated status is improved, try to introduced small amount of solid food in meals at the frequent interval and try to avoid a large amount of solid food at a time. The dietary regimen is to be focused on proteins, fats, carbohydrates, multi-vitamin and mineral for the management of the emaciated person. It is always kept in mind at the time of management of the too lean person, excessive fatty foods items and excess fiber dominated grains and vegetable are to be avoided because they are deficient in energy and consume too much time for digestion.  Treatment of emaciation also includes prescribing a lot of sleep, rest, relaxation, and counseling. In the present context, Rasa means body fluid which is responsible for the nourishment of entire body and mind. Impairment of circulation of body fluid results in diseases and decay. Rasa should be available in adequate quantity and quality for it to circulate through the cells of the body, providing the requisite nourishment they need for proper functioning.  

Sleep in general (verse 35)

 

==== Sleep in general (verse 35) ====

 

The age-old concepts of sleep (Nidra) and its different stages such as Jagrata, swapana and sushupti are comparable to the current concept of sleep and its stages. The problems and pattern of sleep are assessed by observing the activity of brain through Electroencephalogram (EEG) pattern. [70] It is pointed out that wakefulness and stages of sleep have a specific EEG pattern. The wakefulness is associated with Beta and Gama waves frequencies in EEG pattern, which depends on pleasurable or painful stressors of surrounding environment. Stage 1 non-rapid eye movement (NREM) sleep is characterized by slowing down of Beta and Gama wave frequencies, reached to slow down the Alpha wave, and finally reached to Theta wave frequencies in EEG pattern.  At a higher stage of NREM and REM, these brain wave frequencies in EEG pattern gradually decreases, and the person falls into sleep. By observing overall brain activity in EEG pattern, we can say that frequencies of sleep waves are low in wakefulness and it is gradual increases in different stages of sleep. Sleep spindles and K-complexes appeared in EEG pattern in Stage 2 of sleep, while more sleep spindles are observed in Stage 3 of sleep.  The slow wave sleep is also known as high amplitude Delta wave, which is commonly observed in Stages 3 and 4 of sleep in EEG pattern. Low amplitude, mixed frequency waves- a sawtooth wave in EEG pattern observed at REM stage of sleep. [71,72,73]  

The age-old concepts of sleep (Nidra) and its different stages such as Jagrata, swapana and sushupti are comparable to the current concept of sleep and its stages. The problems and pattern of sleep are assessed by observing the activity of brain through Electroencephalogram (EEG) pattern. [70] It is pointed out that wakefulness and stages of sleep have a specific EEG pattern. The wakefulness is associated with Beta and Gama waves frequencies in EEG pattern, which depends on pleasurable or painful stressors of surrounding environment. Stage 1 non-rapid eye movement (NREM) sleep is characterized by slowing down of Beta and Gama wave frequencies, reached to slow down the Alpha wave, and finally reached to Theta wave frequencies in EEG pattern.  At a higher stage of NREM and REM, these brain wave frequencies in EEG pattern gradually decreases, and the person falls into sleep. By observing overall brain activity in EEG pattern, we can say that frequencies of sleep waves are low in wakefulness and it is gradual increases in different stages of sleep. Sleep spindles and K-complexes appeared in EEG pattern in Stage 2 of sleep, while more sleep spindles are observed in Stage 3 of sleep.  The slow wave sleep is also known as high amplitude Delta wave, which is commonly observed in Stages 3 and 4 of sleep in EEG pattern. Low amplitude, mixed frequency waves- a sawtooth wave in EEG pattern observed at REM stage of sleep. [71,72,73]  

Sleep regulation (verse 39-43)  

 

==== Sleep regulation (verse 39-43) ====

 

It is presumed that the sleep physiology is controlled by the hypothalamus and the suprachiasmatic nucleus (SCN) in the brain, which regulates mechanism of homeostatic and circadian rhythm respectively of the body. The actual mechanism of the physiology of sleep is still evolving in biomedical sciences. The sleep is initiated and begins by projections from the SCN to the brain stem. Borbely called projections as Process S (homeostatic) and Process C (Circadian) respectively, who first proposed these two process models in 1982. He pointed out that maximum sleep is the outcome of significant differences between homeostatic and circadian rhythm. [74]   

It is presumed that the sleep physiology is controlled by the hypothalamus and the suprachiasmatic nucleus (SCN) in the brain, which regulates mechanism of homeostatic and circadian rhythm respectively of the body. The actual mechanism of the physiology of sleep is still evolving in biomedical sciences. The sleep is initiated and begins by projections from the SCN to the brain stem. Borbely called projections as Process S (homeostatic) and Process C (Circadian) respectively, who first proposed these two process models in 1982. He pointed out that maximum sleep is the outcome of significant differences between homeostatic and circadian rhythm. [74]   

Effects of sleep (verse 36-38 and 44-49)

 

==== Effects of sleep (verse 36-38 and 44-49) ====

 

Recent conventional evidence suggests that seasonal variation can have an impact on sleep/wake cycle, which is quite interesting and proven the age-old concept of Ayurveda. Recent evidence shows that core temperature of body and secretion of melatonin hormone levels are slightly greater in the month of summer due to prolong the length of light exposure, which imparts significant role in daytime sleep in summer. This is the reason people go to bed early at night and wake up early in the morning in the month of summer.  Sunlight exposure in the morning hours may affect internal biological clock, shifting the timing of the sleep window. The need and function of sleep are the most lacking areas of sleep research in biomedical sciences.  Some of the important ones are- restoration and recovery of body systems, energy conservation, memory consolidation, protection from predation, brain development, and discharge of emotions. [74,76,77,78]

Recent conventional evidence suggests that seasonal variation can have an impact on sleep/wake cycle, which is quite interesting and proven the age-old concept of Ayurveda. Recent evidence shows that core temperature of body and secretion of melatonin hormone levels are slightly greater in the month of summer due to prolong the length of light exposure, which imparts significant role in daytime sleep in summer. This is the reason people go to bed early at night and wake up early in the morning in the month of summer.  Sunlight exposure in the morning hours may affect internal biological clock, shifting the timing of the sleep window. The need and function of sleep are the most lacking areas of sleep research in biomedical sciences.  Some of the important ones are- restoration and recovery of body systems, energy conservation, memory consolidation, protection from predation, brain development, and discharge of emotions. [74,76,77,78]

Sleep about atisthula and atikrisha (verse 51)

 

==== Sleep about atisthula and atikrisha (verse 51) ====

 

Recent evidence suggests that a good sleep plays an important role in the regulation of neuroendocrine, hormonal and metabolic function in the body. Since last few decades, the timing and quality of sleep is gradually hampered due to the affliction of modernization in many ways. At present, the adult and children progressively reduce bedtimes and increases times for other activities, which affect the metabolic functions in many ways. The atisthula and atikrisha are also the outcome of excessive sleep and lack of sleep and vice-versa. Evidence shows that sleep loss for prolong period may provoke the risk of weight gain and morbid obesity. Further, sleep reduction in young adults affects metabolic and endocrine functions in various ways such as- insulin resistance, hyperglycemia, elevated sympathovagal activity, an elevated level of serum glucocorticoid hormone, increased levels of ghrelin, and decreased the level of leptin.  Due to improper and lack of good quality of sleep in adolescents may be important factors to consider in the prevention of childhood obesity.[79] Probably this is the reason that sleep is mentioned in ashṭoninditiya chapter by Charaka about atisthula and atikrisha like other dietary and lifestyle intervention.  

Recent evidence suggests that a good sleep plays an important role in the regulation of neuroendocrine, hormonal and metabolic function in the body. Since last few decades, the timing and quality of sleep is gradually hampered due to the affliction of modernization in many ways. At present, the adult and children progressively reduce bedtimes and increases times for other activities, which affect the metabolic functions in many ways. The atisthula and atikrisha are also the outcome of excessive sleep and lack of sleep and vice-versa. Evidence shows that sleep loss for prolong period may provoke the risk of weight gain and morbid obesity. Further, sleep reduction in young adults affects metabolic and endocrine functions in various ways such as- insulin resistance, hyperglycemia, elevated sympathovagal activity, an elevated level of serum glucocorticoid hormone, increased levels of ghrelin, and decreased the level of leptin.  Due to improper and lack of good quality of sleep in adolescents may be important factors to consider in the prevention of childhood obesity.[79] Probably this is the reason that sleep is mentioned in ashṭoninditiya chapter by Charaka about atisthula and atikrisha like other dietary and lifestyle intervention.  

Insomnia or sleeplessness (verse 52-54)  

 

==== Insomnia or sleeplessness (verse 52-54) ====

 

Anidra of Ayurveda is closely related to Insomnia, or sleeplessness of biomedical sciences. It is a disorder of sleep in which a person is unable to fall in sleep. Nowadays, insomnia is an important area of clinical practice to seek the attention of the physician because a large number of patients come to the hospital suffering from insomnia as secondary conditions.  It is sometimes a functional impairment during awake, which may occur at any age, but it is particularly common in the elderly. Insomnia is either short-term lasting up to 3 hours, or it may be long term lasting for > 3 hours. It may lead to developing dementia, lack of concentration, depression, mental irritation and increases the risk of cardio-vascular accidents along with increases the chances of a roadside accident. [80,81] Regarding its management some drug such as valerian extract has undergone multiple studies and appears to be moderately effective. Similarly, L-Arginine L-aspartate, S-adenosyl-L-homocysteine, and delta sleep inducing peptide (DSIP) appear to be significantly effective in the cases of insomnias. [82, 83]  

Anidra of Ayurveda is closely related to Insomnia, or sleeplessness of biomedical sciences. It is a disorder of sleep in which a person is unable to fall in sleep. Nowadays, insomnia is an important area of clinical practice to seek the attention of the physician because a large number of patients come to the hospital suffering from insomnia as secondary conditions.  It is sometimes a functional impairment during awake, which may occur at any age, but it is particularly common in the elderly. Insomnia is either short-term lasting up to 3 hours, or it may be long term lasting for > 3 hours. It may lead to developing dementia, lack of concentration, depression, mental irritation and increases the risk of cardio-vascular accidents along with increases the chances of a roadside accident. [80,81] Regarding its management some drug such as valerian extract has undergone multiple studies and appears to be moderately effective. Similarly, L-Arginine L-aspartate, S-adenosyl-L-homocysteine, and delta sleep inducing peptide (DSIP) appear to be significantly effective in the cases of insomnias. [82, 83]  

Improper sleep has a harmful impact on carbohydrate metabolism and endocrine function. Besides, it also reduces the metabolic activity in the brain with prolonging lack of sleep. The effects are similar to those seen in normal aging and, therefore, sleep debt may increase the severity of age-related chronic disorders. [85] Lack of sleep for prolonged period has been shown to affect cognitive functions of people involved in versatile activities along with interfering in mood and emotion. This is one of reason to increased tendency to fear, depression, and rage in the people having a deficiency in sleep. The mechanism and effects of sleep deficit are still evolving in the pathophysiology of sleep deficit. [84,85,86]

Improper sleep has a harmful impact on carbohydrate metabolism and endocrine function. Besides, it also reduces the metabolic activity in the brain with prolonging lack of sleep. The effects are similar to those seen in normal aging and, therefore, sleep debt may increase the severity of age-related chronic disorders. [85] Lack of sleep for prolonged period has been shown to affect cognitive functions of people involved in versatile activities along with interfering in mood and emotion. This is one of reason to increased tendency to fear, depression, and rage in the people having a deficiency in sleep. The mechanism and effects of sleep deficit are still evolving in the pathophysiology of sleep deficit. [84,85,86]

The concept of Nidra in Ayurveda is quite comparable to the sleep of biomedical sciences. The Nidra is so important for the maintenance of health and sustaining the life. This is true in the light of contemporary scientific knowledge too. According to Ayurveda, kapha and Tamas are responsible for Nidra even as modern studies attribute the occurrence of sleep to many factors including stimulation of certain areas of the brain . Ayurveda classifies the Nidra based on the mode of origin while modern classification of sleep based on physiological variations seen in association with the different types of sleep. Some factors like food, activities, external stimuli, etc. affect Nidra or sleep. Any variation in the normal sleep pattern is not at all desirable, and they may cause serious health problems that demand proper medical attention.  

The concept of Nidra in Ayurveda is quite comparable to the sleep of biomedical sciences. The Nidra is so important for the maintenance of health and sustaining the life. This is true in the light of contemporary scientific knowledge too. According to Ayurveda, kapha and Tamas are responsible for Nidra even as modern studies attribute the occurrence of sleep to many factors including stimulation of certain areas of the brain . Ayurveda classifies the Nidra based on the mode of origin while modern classification of sleep based on physiological variations seen in association with the different types of sleep. Some factors like food, activities, external stimuli, etc. affect Nidra or sleep. Any variation in the normal sleep pattern is not at all desirable, and they may cause serious health problems that demand proper medical attention.  

Conclusion: The present chapter reveals that the clinical entity, consequences, and management of too obese, too lean, insomnia, along with categorization of good built, information and mechanism of sleep and measures to induce good sleep was fairly well known even in the classical period of Ayurveda, which is comparable to the latest development in this field. The Ayurvedic classics vividly describe the etiological factors, pathogenesis, clinical presentation, complications and its categories and treatment modalities of too obese, which has a striking resemblance to the latest development in this field. The samprapti (pathogenesis) of this disease is based on the specific doṣha-dushya pattern. Besides, the special emphasis placed on vitiation of medas. The age-old ideas are now getting strong scientific support for the emerging concept of prediabetes, Insulin resistance, and metabolic syndrome, signifying the role of lipid disorders in the pathogenesis, hypometabolic state (ama state) and immunodeficiency in these disorders. Numbers of complications have been described in this context including prameha, GI problems, skin disorders, etc. It is presumed that in the diathesis of complications, impaired status of agni, ojas and medas play an important role6.  

 

On The overall assessment, the concept of overweight and obesity, emaciation, sleep and its type, indications, and contraindications of day sleep, the role of sleep in obesity, causes of insomnia and features of good and bad sleep along with features of good body built was a well-known entity since antiquity. The available descriptions appear very contemporary and scientific. Certain therapeutic modalities have close resemblance with several non-drug approaches of modern medicine. These modalities can be combined judiciously for individualized prevention and cure of too obese, too lean and insomnia. The current approaches and management of too obese and too lean along with insomnia are still not satisfactory in the conventional system of medicine; this chapter provides a new outlook to scholars and researchers of Ayurveda, which is based on current publications and reports.  

==== Conclusion ====

 

The present chapter reveals that the clinical entity, consequences, and management of too obese, too lean, insomnia, along with categorization of good built, information and mechanism of sleep and measures to induce good sleep was fairly well known even in the classical period of Ayurveda, which is comparable to the latest development in this field. The Ayurvedic classics vividly describe the etiological factors, pathogenesis, clinical presentation, complications and its categories and treatment modalities of too obese, which has a striking resemblance to the latest development in this field. The samprapti (pathogenesis) of this disease is based on the specific doṣha-dushya pattern. Besides, the special emphasis placed on vitiation of medas. The age-old ideas are now getting strong scientific support for the emerging concept of prediabetes, Insulin resistance, and metabolic syndrome, signifying the role of lipid disorders in the pathogenesis, hypometabolic state (ama state) and immunodeficiency in these disorders. Numbers of complications have been described in this context including prameha, GI problems, skin disorders, etc. It is presumed that in the diathesis of complications, impaired status of agni, ojas and medas play an important role6.  

 

On The overall assessment, the concept of overweight and obesity, emaciation, sleep and its type, indications, and contraindications of day sleep, the role of sleep in obesity, causes of insomnia and features of good and bad sleep along with features of good body built was a well-known entity since antiquity. The available descriptions appear very contemporary and scientific. Certain therapeutic modalities have close resemblance with several non-drug approaches of modern medicine. These modalities can be combined judiciously for individualized prevention and cure of too obese, too lean and insomnia. The current approaches and management of too obese and too lean along with insomnia are still not satisfactory in the conventional system of medicine; this chapter provides a new outlook to scholars and researchers of Ayurveda, which is based on current publications and reports.

=== Glossary ===

=== Glossary ===