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'''Principles of Diagnosis and Management of Metabolic syndrome and Obesity in Ayurveda'''

|description= Principles of diagnosis and management of obesity and metabolic syndrome in Ayurveda are described. 

{{Infobox

{{Infobox

|label2 = Author

|label2 = Author

|data2 = Dr. Sabnis Mukund¹

|data2 = Dr. Sabnis Mukund¹

|label3 = Reviewer  

|label3 = Reviewer  

|data3 = Basisht G.²

|data3 = Basisht G.²

|data8 = Under process

|data8 = Under process

}}  

}}  

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The metabolic syndrome is a group of several cardiovascular risk factors like insulin resistance, obesity, atherogenic dyslipidemia and hypertension. These conditions are interrelated and share underlying mediators, mechanisms and pathways. There has been recent controversy about its definition and its utility. Metabolic syndrome is not an ultimate diagnosis.  Metabolic syndrome is a subgroup of patients with shared pathophysiology who are at high risk of developing cardiovascular disease and type 2 diabetes. Pathophysiology and disease pathogenesis can be better understood by observing the clinical features of metabolic syndrome and their interrelation.

Metabolic syndrome is a group of several cardiovascular risk factors like insulin resistance, obesity, atherogenic dyslipidemia and hypertension. These conditions are interrelated and share underlying mediators, mechanisms and pathways. There has been recent controversy about its definition and its utility. Metabolic syndrome is not an ultimate diagnosis.  Metabolic syndrome is a subgroup of patients with shared pathophysiology who are at high risk of developing cardiovascular disease and type 2 diabetes. Pathophysiology and disease pathogenesis can be better understood by observing the clinical features of metabolic syndrome and their interrelation.

[[Ayurveda]] has a vast scope in the management of metabolic syndrome. Clubbing of modern medicine concepts with Ayurveda is essential for this. The pathophysiology of metabolic syndrome shall be clubbed with disorders due to overnutrition (santarpanajanya vyadhis) in [[Ayurveda]].  [Cha.Sa. [[Sutra Sthana]] 23/3-5]

[[Ayurveda]] has a vast scope in the management of metabolic syndrome. Clubbing of modern medicine concepts with Ayurveda is essential for this. The pathophysiology of metabolic syndrome shall be clubbed with disorders due to overnutrition (santarpanajanya vyadhi) in [[Ayurveda]].  [Cha.Sa. [[Sutra Sthana]] 23/3-5]

==Definition==

==Definition==

[[File:Def_of_Metabolic_syndrome.JPG|500px|'''Figure 1: Definition of metabolic syndrome'''|thumb]]

[[File:Def_of_Metabolic_syndrome.JPG|500px|'''Figure 1: Definition of metabolic syndrome'''|thumb]]

A comprehensive definition of metabolic syndrome and its key features would facilitate research on its causes.[Fig. 1] It can lead to new insights into pharmacological, and lifestyle treatment approaches. In metabolic diseases, only pharmacological interventions don’t give results. Lifestyle management is very much essential with pharmacological interventions.

A comprehensive definition of metabolic syndrome and its key features would facilitate research on its causes.[Fig.1]<ref>Paul L. Huang.A comprehensive definition for metabolic syndrome. Dis Model Mech. 2009 May-Jun; 2(5-6): 231–237.doi: 10.1242/dmm.001180</ref> It can lead to new insights into pharmacological, and lifestyle treatment approaches. In metabolic diseases, only pharmacological interventions don’t give results. Lifestyle management is very much essential with pharmacological interventions.

==Factors in metabolic syndrome==

==Factors in metabolic syndrome==

The criterion to define ‘metabolic syndrome’ includes different parameters like obesity, hyperglycemia, dyslipidemia, hypertension. As per [[Ayurveda]], all the endogenous diseases occur invariably due to the vitiation of [[vata]], [[pitta]] and [[kapha]]. The diagnosis is made by examining location, signs and symptoms, causes of vitiation of three [[dosha]] in any condition. [Cha.Sa. [[Sutra Sthana]] 19/5]

The criteria to define ‘metabolic syndrome’ includes different parameters like obesity, hyperglycemia, dyslipidemia, hypertension. As per [[Ayurveda]], all the endogenous diseases occur invariably due to the vitiation of [[vata]], [[pitta]] and [[kapha]]. The diagnosis is made by examining location, signs and symptoms, causes of vitiation of three [[dosha]] in any condition. [Cha.Sa. [[Sutra Sthana]] 19/5]

==Causes==

==Causes==

   

   

The causes of all endogenous diseases [nijaroga] can lead to metabolic diseases. [Cha.Sa.[[Sutra Sthana]] 18/6]

The causes of all endogenous diseases [nija roga] can lead to metabolic diseases. [Cha. Sa.[[Sutra Sthana]] 18/6]

Following factors shall be considered while understanding diagnosis and treatment of metabolic syndrome:  

Following factors shall be considered while understanding diagnosis and treatment of metabolic syndrome:  

*Role of digestion and metabolism ([[agni]])

*Role of digestion and metabolism ([[agni]])

*Lifestyle (vihara), including physical activities  

*Lifestyle (vihara), including physical activities  

==Body frames==

==Body frames==

The type of body frame of a patient with metabolic syndrome should be considered. As per [[Ayurveda]] obese (sthula), lean (krisha) and medium (madhyama) are the three types of body frames. [Su.Sa. Sutra Shtana 35/33] This can be either physical or physiological. As per the blood parameters, a thin-built person can also be obese. They are called thin obese patients. There the patient is having adipose tissue ([[meda dathu]]) vitiation. At the same time, an obese patient may not require any treatment because of excellent adipose tissue quality (medasara). The management also varies according to body frames. Bringing Ayurvedic and modern concepts about metabolic syndrome can make the treatment easy.  

The type of body frame of a patient with metabolic syndrome should be considered. As per [[Ayurveda]] obese (sthula), lean (krisha) and medium (madhyama) are the three types of body frames. [Su.Sa. Sutra Shtana 35/33] These are the  physiological variations of body frame. As per blood parameters, a thin-built person can also be obese. They are called thin obese patients. There the patient is having adipose tissue ([[meda dhatu]]) vitiation. At the same time, an obese patient may not require any treatment because of excellent adipose tissue quality (meda sara). The management also varies according to body frames. Bringing Ayurvedic and modern concepts about metabolic syndrome can make the treatment easy.  

==Quality of body tissues (dhatusarata)==

==Quality of body tissues (dhatu sarata)==

   

   

Sarata means the optimum quality of body tissues. It is one of the assessment parameters to check the health of tissues. Physician may sometimes make a wrong judgement by just looking at the patient. A patient having corpulent or a big physique may not be strong or healthy. On the other hand,  it is observed that some persons having small body and leanness are strong, like the tiny ants carrying a big load. This is why the optimum quality of tissues ([[dhatu]] sarata) shall be examined before understanding a patient's strength. [Cha.Sa. [[Vimana Sthana]] 8/115]

Sarata means the optimum quality of body tissues. It is one of the assessment parameters to check the health of tissues. Physician may sometimes make a wrong judgement by just looking at the patient. A patient having corpulent or a big physique may not be strong or healthy. On the other hand,  it is observed that some persons having small body and leanness are strong, like the tiny ants carrying a big load. This is why the optimum quality of tissues ([[dhatu]] sarata) shall be examined before understanding a patient's strength. [Cha.Sa. [[Vimana Sthana]] 8/115]

In contemporary practices, while treating metabolic syndrome, lipid profile is generally taken into account. When cholesterol and LDL are high, it is usually considered a high-risk group. However, the oxidized state should also be considered. Unless and until the LDL is getting oxidized, it will not create any pathological conditions.The lipid profile is not an indicator of optimum quality of adipose tissue (medasara). In Ayurvedic management of metabolic syndrome, these are fundamental concepts that should be taken to account. So as far as Ayurveda is considered, these types of investigations or criteria are very superficial and have a very limited scope in treating metabolic disorders.

In contemporary practices, while treating metabolic syndrome, lipid profile is generally taken into account. When total cholesterol and LDL are high, it is usually considered a high-risk group. However, the oxidized state should also be considered. Unless and until the LDL is getting oxidized, it will not create any pathological conditions. The lipid profile is not an indicator of optimum quality of adipose tissue (meda sara). In Ayurvedic management of metabolic syndrome, these are fundamental concepts that should be taken to account. So as far as Ayurveda is considered, these types of investigations or criteria are very superficial and have a very limited scope in treating metabolic disorders.

Quality of tissue (sarata) and blood parameters should be assessed before treating a patient. The biomarkers used in modern medical practice are insufficient and often inappropriate to decide the patient's diagnosis, prognosis, and treatment. The same is true while applying them in diagnostic and research of [[Ayurveda]] perspectives.

Quality of tissue (sarata) and blood parameters should be assessed before treating a patient. The biomarkers used in modern medical practice are insufficient and often inappropriate to decide the patient's diagnosis, prognosis, and treatment. The same is true while applying them in diagnostic and research of [[Ayurveda]] perspectives.

In most of the researches in obesity, weight is considered as the main parameter. However, it is a very superficial parameter. Weight reduction to make the obese person thin is a primary goal in general practice. However, the most crucial concern in treating an obese person is not to make the person thin but to transform an unhealthy obese person to a healthy obese person. [Su.Sa. Sutra Sthana 35/34] If the person has adipose tissue with optimum quality (medasara), it is challenging to reduce weight. Similarly, in hyperhomocysteinemia, one should see whether the patient is with optimal quality of blood tissue (raktasara), before treating the person. So while treating obesity and metabolic syndrome through [[Ayurveda]], the targets should be different, and the biomarkers should be more specific.  

In most of the researches in obesity, weight is considered as the main parameter. However, it is a very superficial parameter. Weight reduction to make the obese person thin is a primary goal in general practice. However, the most crucial concern in treating an obese person is not to make the person thin but to transform an unhealthy obese person to a healthy obese person. [Su.Sa. Sutra Sthana 35/34] If the person has adipose tissue with optimum quality (meda sara), it is challenging to reduce weight. Similarly, in hyperhomocysteinemia, one should see whether the patient is with optimal quality of blood tissue (rakta sara), before treating the person. So while treating obesity and metabolic syndrome through [[Ayurveda]], the targets should be different, and the biomarkers should be more specific.  

==Selection of biomarker==

==Selection of biomarker==

The selection of biomarker depends on the type of disorder and drug used for therapy. The correct selection of biomarker sheds light on the mode of action of that particular drug.  The medicines described for the treatment of obesity vary in their mode of action. The different medicines for reducing body tisues (lekhana) act differently. Some medicines work on fatty liver; some on skeletal muscles; some have insulin stimulating action; and some have anti oxidant activities specific to the adipose tissue ([[meda dhatu]]). So depending on the underlying pathology and drug, the biomarker should be selected. If we suspect inflammatory involvement, then the best biomarker is either Adiponectin or high sensitive c reactive protein (HSCRP). Adiponectin level suggests the presence of inflammation, tendency of atherogenesis, or presence of insulin resistance at the cellular level. In different types of metabolic disorders like hypercholesterolemia, hyperhomocysteinemia etc. the specific biomarker should be selected.

The selection of biomarker depends on the type of disorder and drug used for therapy. The correct selection of biomarker sheds light on the mode of action of that particular drug.  The medicines described for the treatment of obesity vary in their mode of action. The different medicines for reducing body tissues (lekhana) act differently. Some medicines work on fatty liver; some on skeletal muscles; some have insulin sensitizing action; and some have anti oxidant activities specific to the adipose tissue ([[meda dhatu]]). So depending on the underlying pathology and drug, the biomarker should be selected. If we suspect inflammatory involvement, then the best biomarker is either Adiponectin or high sensitive c reactive protein (HSCRP). Adiponectin level suggests the presence of inflammation, tendency of atherogenesis, or presence of insulin resistance at the cellular level. In different types of metabolic disorders like hypercholesterolemia, hyperhomocysteinemia etc. the specific biomarker should be selected.

==Disorders due to overnutrition (santarpanajanyavyadhi)==

==Disorders due to overnutrition (santarpanajanya vyadhi)==

===Causes===

===Causes===

   

   

'''Dietary causes:''' Excess intake of unctuous (snigdha), sweet (madhura), heavy to digest (guru), slimy (picchila) foods, new grains, new fermented drinks, the flesh of animals living in the marshy area or water, cow milk and its products, jaggery products, foods prepared with rice batter leads to metabolic diseases. [Cha.Sa. [[Sutra Sthana]] 23/3-4]

====Dietary causes====

 

Excess intake of unctuous (snigdha), sweet (madhura), heavy to digest (guru), slimy (picchila) foods, new grains, new fermented drinks, the flesh of animals living in the marshy area or water, cow milk and its products, jaggery products, foods prepared with rice batter leads to metabolic diseases. [Cha.Sa. [[Sutra Sthana]] 23/3-4]

'''Lifestyle factors:''' Less physical activities, sleeping in the daytime, excessive indulgence in lying, sitting, and sexual activities. [Cha.Sa. [[Sutra Sthana]] 23/3-4]

==== Lifestyle factors ====

Less physical activities, sleeping in the daytime, excessive indulgence in lying, sitting, and sexual activities. [Cha.Sa. [[Sutra Sthana]] 23/3-4]

===Diseases involved===

===Diseases involved===

Some of the underlying biochemical principles and pathological factors that result in anabolic disorders are not addressed while giving Ayurvedic treatment. Those are:

Some of the underlying biochemical principles and pathological factors that result in anabolic disorders are not addressed while giving Ayurvedic treatment. Those are:

#Concept of oxidative stress

#Concept of oxidative stress

#Mitochondrial dysfunction

#Mitochondrial dysfunction

#Food including and portion size  

#Food including and portion size  

#Lifestyle and exercise capacity

#Lifestyle and exercise capacity

#Antagonistic food (viruddha anna and malinaahara)

#Antagonistic food (viruddha anna and malina ahara)

#Daily and seasonal regimens ([[dinacharya]] and ritucharya)

#Daily and seasonal regimens ([[dinacharya]] and ritucharya)

===Prognosis===

===Prognosis===

   

   

All metabolic disorders require long-term treatment and are difficult to cure (kashtasadhya). If the medicines need to be given for short duration, then only phyto-pharmacology can be considered. If long-term therapy is needed as in metabolic disorders, the above-mentioned factors must be considered.

All metabolic disorders require long-term treatment and are difficult to cure (kashta sadhya). If the medicines need to be given for short duration, then only phyto-pharmacology can be considered. If long-term therapy is needed as in metabolic disorders, the above-mentioned factors must be considered.

   

   

For e.g: In metabolic disorder, viruddhaahara or malinaahara (antagonistic food) is an important factor. Consumption of wine with cheese, fruit juices in early morning, milkshakes with non-vegetarian foods, non-vegetarian food with curd are antagonists (viruddha). With the help of molecular biology and biochemistry, clear explanations are available about their antagonistic effect (viruddha).

For e.g: In metabolic disorder, viruddha ahara or malina ahara (antagonistic food) is an important factor. Consumption of wine with cheese, fruit juices in early morning, milkshakes with non-vegetarian foods, non-vegetarian food with curd are antagonists (viruddha). With the help of molecular biology and biochemistry, clear explanations are available about their antagonistic effect (viruddha).

==Obesity – Diagnosis and Ayurvedic management==

==Obesity – Diagnosis and Ayurvedic management==

'''Based on the fat cell characteristics'''  

'''Based on the fat cell characteristics'''  

#Mildly obese: Enlarged fat cells (hypertrophic obesity)

#Mildly obese: Enlarged fat cells (hypertrophic obesity)

#Moderately obese: Fats are larger in size and more in number

#Moderately obese: Fats are larger in size and more in number

'''Based on the histopathology of fat cells'''  

'''Based on the histopathology of fat cells'''  

#Hyperplastic obesity: The number of fats is increased

#Hyperplastic obesity: The number of fats is increased

#Hypertropic obesity: Enlargement of fat cells happens. It is seen more in metabolic disorders.  

#Hypertropic obesity: Enlargement of fat cells happens. It is seen more in metabolic disorders.  

'''Based on the distribution of fat'''   

'''Based on the distribution of fat'''   

#Generalized

#Generalized

#Central (Android obesity): Involves only the trunk and neck

#Central (Android obesity): Involves only the trunk and neck

Due to the obstruction of body channels by adipose tissue ([[meda dhatu]]), [[vata]][[dosha]] is trapped inside the gut (koshtha). The [[vata]][[dosha]] continuously stimulates the [[agni]] (digestion and metabolism) and increases the demand for food.  It leads to voracious appetite without the sense of satiety.  [Cha.Sa.[[Sutra Sthana]] 21/5-6] This pathogenesis can be related with strong insulin resistance at hepatic or pancreatic level or leptin resistance at hypothalamus level.  These pathologies should be broken while treating obesity.

Due to the obstruction of body channels by adipose tissue ([[meda dhatu]]), [[vata]][[dosha]] is trapped inside the gut (koshtha). The [[vata]][[dosha]] continuously stimulates the [[agni]] (digestion and metabolism) and increases the demand for food.  It leads to voracious appetite without the sense of satiety.  [Cha.Sa.[[Sutra Sthana]] 21/5-6] This pathogenesis can be related with strong insulin resistance at hepatic or pancreatic level or leptin resistance at hypothalamus level.  These pathologies should be broken while treating obesity.

In pathogenesis of prameha, the [[kapha]][[dosha]] and fat/adipose tissue ([[meda dhatu]]) mix with muscle ([[mamsa dhatu]]) and body fluids (kleda) which are already excessive in quantity. [Cha.Sa.[[Nidana Sthana]] 4/8] The disease prameha can be considered as a prototype for all metabolic disorders. So with [[meda dhatu]] and [[mamsa dhatu]], kleda should also be considered in metabolic disorders.  The laxity occurs due to excess accumulation of kleda in body tissues. It results in oozing or discharge (abishyandana) into body channels. This creates low-grade inflammation at cellular level.  The pathogenesis is as shown in figure 2.

In pathogenesis of prameha, the [[kapha]][[dosha]] and fat/adipose tissue ([[meda dhatu]]) mix with muscle ([[mamsa dhatu]]) and body fluids (kleda) which are already excessive in quantity. [Cha.Sa.[[Nidana Sthana]] 4/8] The disease prameha can be considered as a prototype for all metabolic disorders. So with [[meda dhatu]] and [[mamsa dhatu]], kleda should also be considered in metabolic disorders.  The laxity occurs due to excess accumulation of kleda in body tissues. It results in unwanted moisture or fluid (abishyandana) into body channels. This creates low-grade inflammation at cellular level.  The pathogenesis is as shown in figure 2.

====Role of body fluids (kleda)====

====Role of body fluids (kleda)====

Kleda is a physiological factor responsible for moisture.[Cha.Sa. Sthana??] It is essential to properly digest food and get food assimilated into body tissues ([[dhatu]]). It is one among the factors which are responsible for the transformation of food (aharaparinamakara bhava).[Cha.Sa. [[Sharira Sthana]] 6/14] In the normal state, it eases digestion. It is retained by sweat to moisten the skin. Excess of it is excreted through urine. When vitiated, it induces laxity, oozing or dampness in body tissues and thereby decline in their functions. It liquefies the [[dhatu]] quantitatively. It is closely associated with vitiated [[kapha]][[dosha]] and adipose tissue ([[meda dhatu]]).  It can result in rotting, putrification and decomposition of body tissues. Kleda can be ascribed as an inflammation-creating factor at cellular level in body tissues. In metabolic syndrome, it creates inflammation of adipose tissue ([[meda dhatu]]). Excess kleda disturbs the microenvironment of the tissues.  Vitiated kleda can result in cellular and tissue laxity, low-grade inflammation, mitochondrial dysfunction, or endoplasmic reticulum stress.   

Kleda is a physiological factor responsible for moisture. It is essential to properly digest food and get food assimilated into body tissues ([[dhatu]]). It is one among the factors which are responsible for the transformation of food (aharaparinamakara bhava).[Cha.Sa. [[Sharira Sthana]] 6/14] In the normal state, it eases digestion. It is retained by sweat to moisten the skin. Excess of it is excreted through urine. When vitiated, it induces laxity, oozing or dampness in body tissues and thereby decline in their functions. It liquefies the [[dhatu]] quantitatively. It is closely associated with vitiated [[kapha]][[dosha]] and adipose tissue ([[meda dhatu]]).  It can result in rotting, putrification and decomposition of body tissues. Kleda can be ascribed as an inflammation-creating factor at cellular level in body tissues. In metabolic syndrome, it creates inflammation of adipose tissue ([[meda dhatu]]). Excess kleda disturbs the microenvironment of the tissues.  Vitiated kleda can result in cellular and tissue laxity, low-grade inflammation, mitochondrial dysfunction, or endoplasmic reticulum stress.   

Kleda can lead to altered fluid distribution in body. It is a complication of lowered metabolism at cell level (dhatu agnimandya). The altered states include relative over hydration or cell dehydration, abnormal fluid regulation, and normal adaptation to hyperosmotic stress. These states could have different implications in obesity prevention and treatment. Therefore, kleda is an essential factor in treating obesity or any metabolic disorder.

Kleda can lead to altered fluid distribution in body. It is a complication of lowered metabolism at cell level (dhatu agnimandya). The altered states include relative over hydration or cell dehydration, abnormal fluid regulation, and normal adaptation to hyperosmotic stress. These states could have different implications in obesity prevention and treatment. Therefore, kleda is an essential factor in treating obesity or any metabolic disorder.

Muscle tissue ([[mamsa dhatu]]) is one of the vitiated factors ([[dushya]]) in obstinate urinary disorders including diabetes mellitus (prameha). The sequence of the pathology of prameha points to vitiation of adipose tissue ([[meda dhatu]])at first. This [[meda dhatu]] infiltrates muscle tissue ([[mamsa dhatu]]). [[Mamsa dhatu]] is vitiated in prameha due to excess [[kapha]] and obstruction of body channels (avaranajanaya prameha). This indicates that smooth muscles and skeletal muscles are affected in prameha. Fatty infiltration in skeletal muscles and oxidized lipid deposition in the endothelial layer of arteries is the primary pathology observed in muscles. This pathology develops strong insulin resistance at the skeletal muscle level. This creates more hunger pains and increases food intake. This pathology can be compared with hyperfunctioning of [[agni]] due to trapped [[vata][[dosha]] as mentioned earlier.

Muscle tissue ([[mamsa dhatu]]) is one of the vitiated factors ([[dushya]]) in obstinate urinary disorders including diabetes mellitus (prameha). The sequence of the pathology of prameha points to vitiation of adipose tissue ([[meda dhatu]])at first. This [[meda dhatu]] infiltrates muscle tissue ([[mamsa dhatu]]). [[Mamsa dhatu]] is vitiated in prameha due to excess [[kapha]] and obstruction of body channels (avaranajanaya prameha). This indicates that smooth muscles and skeletal muscles are affected in prameha. Fatty infiltration in skeletal muscles and oxidized lipid deposition in the endothelial layer of arteries is the primary pathology observed in muscles. This pathology develops strong insulin resistance at the skeletal muscle level. This creates more hunger pains and increases food intake. This pathology can be compared with hyperfunctioning of [[agni]] due to trapped [[vata][[dosha]] as mentioned earlier.

   

   

The application of powder massage (udvartana) in disorders due to overnutrition (santarpanajanyavyadhi) can be justified at this juncture. Udvartana acts directly on the skeletal muscles and embedded arteries. It can probably remove the fatty infiltrations and reverse the disease pathophysiology.

The application of powder massage (udvartana) in disorders due to overnutrition (santarpanajanya vyadhi) can be justified at this juncture. Udvartana acts directly on the skeletal muscles and embedded arteries. It can probably remove the fatty infiltrations and reverse the disease pathophysiology.

===Consequences of obesity===

===Consequences of obesity===

Obesity can lead to many complications and comorbid conditions as shown in figure 3.

Obesity can lead to many complications and comorbid conditions as shown in figure 3.

==Principles of management==

== Principles of management ==

Breaking the chain of pathogenesis is the treatment. Merely weight reduction do not indicate management of obesity. It is an outcome of obesity management. The focus of treatment should be to provide nutrition to other tissues ([[dhatu]]). Improvement in the functioning of [[agni]] at each level is of prime importance in treating the metabolic disorder.

Breaking the chain of pathogenesis is the treatment. Merely weight reduction do not indicate management of obesity. It is an outcome of obesity management. The focus of treatment should be to provide nutrition to other tissues ([[dhatu]]). Improvement in the functioning of [[agni]] at each level is of prime importance in treating the metabolic disorder.

Ayurvedic treatments are highly personalized. One medicine does not suit all. While treating obesity, the different underlying causes such as insulin resistance, leptin resistance, fatty liver, PCOS, drug-induced obesity etc. should be considered. These pathologies should be targetted instead of targeting the fats. Obesity and its complications should be targeted in single management. As far as possible, metallic preparation should not be used for obesity management. There are no confirmatory research works or evidence to show it is safe to use. Intake of ghee is not advised in this condition. Instead of ghee, sesame oil is used for the management of obesity and metabolic disorders.

Ayurvedic treatments are highly personalized. One medicine does not suit all. While treating obesity, the different underlying causes such as oxidation, insulin resistance, leptin resistance, fatty liver, PCOS, drug-induced obesity etc. should be considered. These pathologies should be targeted instead of targeting the fats. Obesity and its complications should be targeted in single management. As far as possible, metallic preparation should not be used for obesity management. There are no confirmatory research works or evidence to show it is safe to use. Intake of ghee is not advised in this condition. Instead of ghee, sesame oil is used for the management of obesity and metabolic disorders.

The following principles are applied in the management of metabolic syndrome and obesity.  

The following principles are applied in the management of metabolic syndrome and obesity.  

#Controlling the cause (hetu)  

#Controlling the cause (hetu)  

#Correcting the obstruction in channels (srotorodha)

#Correcting the obstruction in channels (srotorodha)

This pharmaco-therapeutics is focused on correcting the following pathologies:  

This pharmaco-therapeutics is focused on correcting the following pathologies:  

#Oxidative stress

#Oxidative stress

#Mitochondrial dysfunction

#Mitochondrial dysfunction

#Nutrition  

#Nutrition  

#External purification (bahya samshodhana): Powder massage (udavartana), sitz bath (avagaha), Oil dripping or decoction on the body (parisheka), application of paste, powder (lepana).

#External purification (bahya samshodhana): Powder massage (udavartana), sitz bath (avagaha), Oil dripping or decoction on the body (parisheka), application of paste, powder (lepana).

#Internal purification therapies (abhyantara samshodhana): Therapeutic emesis ([[vamana]]), purgation ([[virechana]]),  nasal administration ([[nasya]]), therapeutic decoction enema (niruha [[basti]])

#Internal purification therapies (abhyantara samshodhana): Therapeutic emesis ([[vamana]]), purgation ([[virechana]]),  nasal administration ([[nasya]]), therapeutic decoction enema (niruha [[basti]])

'''Dietary management:'''

==== Dietary management ====

   

   

'''Avoiding heavy to digest foods:'''

'''Avoiding heavy to digest foods:'''

In fatty liver, in the first stage, insulin resistance is observed at the hepatocytes. There is a reduction in fatty oxidation; increase in fatty acid influx into liver; increased lipogenesis and increased triglycerides. The second stage is lipid peroxidation. So the management should target lipid peroxidation, TNF-alpha, cytokine cascade, reducing the liquid/slimy content (kleda), correcting the metabolism ([[agni]]) etc.

In fatty liver, in the first stage, insulin resistance is observed at the hepatocytes. There is a reduction in fatty oxidation; increase in fatty acid influx into liver; increased lipogenesis and increased triglycerides. The second stage is lipid peroxidation. So the management should target lipid peroxidation, TNF-alpha, cytokine cascade, reducing the liquid/slimy content (kleda), correcting the metabolism ([[agni]]) etc.

Ayurvedic interventions considerably control the hormones - adiponectin and leptin secreted by adipose tissue. The treatment creates insulin sensitivity and reduces inflammation at adipocyte level. Adiponectin is inversely proportional to obesity. If weight is more, adiponectin level is less and vice versa. However, in people having optimum [[meda]] (medasara), adiponectin level increases with weight.  

Ayurvedic interventions considerably control the hormones - adiponectin and leptin secreted by adipose tissue. The treatment creates insulin sensitivity and reduces inflammation at adipocyte level. Adiponectin is inversely proportional to obesity. If weight is more, adiponectin level is less and vice versa. However, in people having optimum [[meda]] (meda sara), adiponectin level increases with weight.  

'''Effect of therapeutic enema (basti) as a treatment in obesity'''

=== Effect of therapeutic enema ( [[basti]]) as a treatment in obesity===

    

    

Therapeutic enema with weight-reducing drugs (lekhana [[basti]]) has very important role in correcting the gut flora and reducing inflammation at the intestinal level. Short-chain fatty acids, which are created by the fermicutes bacteria, are transformed from the intestines to the liver. The action of [[basti]] may not be evident in 10 or 20 days. However, in due course of time, hormonal changes happen. The hormones like Ghrelin, GLP-1, GLP-2, GIP etc. can be used as biomarkers for the same.

Therapeutic enema with weight-reducing drugs (lekhana [[basti]]) has very important role in correcting the gut flora and reducing inflammation at the intestinal level. Short-chain fatty acids, which are created by the firmicutes bacteria, are transformed from the intestines to the liver. The action of [[basti]] may not be evident in 10 or 20 days. However, in due course of time, hormonal changes happen. The hormones like Ghrelin, GLP-1, GLP-2, GIP etc. can be used as biomarkers for the same.

'''Management of erectile dysfunction (klaibya or kruchhravyavaya):'''

=== Management of erectile dysfunction (klaibya or kruchhra vyavaya) ===

Erectile dysfunction is commonly observed in obese male patients as complication. Insulin resistance is the emerging risk factor in metabolic syndrome. Obesity and sedentary lifestyle are the risk factors for erectile dysfunction. These are also the risk factors for endothelial dysfunction. As the penile artery is obstructed due to fat deposition, the lumen of the artery gets reduced. This finally results in erectile dysfunction. This narrowing may happen in coronary arteries, resulting in cardiovascular diseases. In such a condition aphrodisiac ([[vajikarana]]) treatment won’t work. In such conditions, the drugs selected should have the property of secreting nitric oxide. This dilates the occluded arteries and thus corrects the pathology. E.g.: Garlic (lashuna) is one of the ideal drugs for treating such conditions.

Erectile dysfunction is commonly observed in obese male patients as complication. Insulin resistance is the emerging risk factor in metabolic syndrome. Obesity and sedentary lifestyle are the risk factors for erectile dysfunction. These are also the risk factors for endothelial dysfunction. As the penile artery is obstructed due to fat deposition, the lumen of the artery gets reduced. This finally results in erectile dysfunction. This narrowing may happen in coronary arteries, resulting in cardiovascular diseases. In such a condition aphrodisiac ([[vajikarana]]) treatment won’t work. In such conditions, the drugs selected should have the property of secreting nitric oxide. This dilates the occluded arteries and thus corrects the pathology. E.g.: Garlic (lashuna) is one of the ideal drugs for treating such conditions.

==Conclusion==

== Conclusion ==

   

   

In the treatment of metabolic disorders and obesity, primarily the cause must be avoided. The causes like heavy, cold, slimy foods items should be avoided. A sedentary lifestyle must be corrected. The obstruction in the body channels, accumulation of toxic metabolic wastes ([[ama]]) and digestion and metabolism ([[agni]]) must be corrected at multiple levels. Correcting the nutritional status of all other [[dhatu]] except adipose tissue ([[meda]]), keeping all the pathways intact for the proper nourishment of body tissues, and [[rasayana]] should be done.  

In the treatment of metabolic disorders and obesity, primarily the cause must be avoided. The causes like heavy, cold, slimy foods items should be avoided. A sedentary lifestyle must be corrected. The obstruction in the body channels, accumulation of toxic metabolic wastes ([[ama]]) and digestion and metabolism ([[agni]]) must be corrected at multiple levels. Correcting the nutritional status of all other [[dhatu]] except adipose tissue ([[meda]]), keeping all the pathways intact for the proper nourishment of body tissues, and [[rasayana]] should be done.  

'''Q. (Dr. Jayprakash Ram):''' Do the lipid levels change as per individual. How to assess what is normal value for an individual?.

'''Q. (Dr. Jayprakash Ram):''' Do the lipid levels change as per individual. How to assess what is normal value for an individual?.

'''A:''' Yes.The lipid levels changes as per individuals. The lipid levels also changes with age, desha (geographical conditions/body constitution) and [[prakriti]] (doshic constitution). The normal values cannot be generalized. It has to be correlated with the optimum quality (sarata) of tissues. If the lipids levels are deranged, further investigations like insulin resistance, HSCRP, homocysteine etc can be done. If these investigations are normal, the abnormal lipids values should be considered as normal to that particular individual.

'''A:''' Yes.The lipid levels changes as per individuals. The lipid levels also changes with age, desha (geographical conditions/body constitution) and [[prakriti]] (doshic constitution). The normal values cannot be generalized. It has to be correlated with the optimum quality (sarata) of tissues. If the lipids levels are deranged, further investigations like insulin resistance, HSCRP, homocysteine etc. can be done. If these investigations are normal, the abnormal lipids values should be considered as normal to that particular individual.

   

   

'''Q.''' Please enlighten on the role of bhutagni ([[agni]] at the level of [[panchamahabhuta]]) in obesity. How to assess it clinically?

'''Q. (Dr. Yogesh Deole)''' Please enlighten on the role of bhutagni ([[agni]] at the level of [[panchamahabhuta]]) in obesity. How to assess it clinically?

   

   

'''A:''' Bhutagni works like a vehicle. Bhutagni carries the fuel (food) to the tissues ([[dhatu]]). The fuel is filled in a vehicle (body gut) only when it is empty (hungry state). If we overfill the tank (gut) beyond its capacity, it leads to engine dysfunction (agnivaishamya). Likewise, when there is excess body fluid (kleda) formation,aapbhutagni becomes less. In this condition, the diet control and medicines advised should work on aapmahabhutaagni. The water intake must be restricted. The astringent medicines should be given as they have kledashoshana (drying) and stambhana (obstructing) property.

'''A:''' Bhutagni works like a vehicle. Bhutagni carries the fuel (food) to the tissues ([[dhatu]]). The fuel is filled in a vehicle (body gut) only when it is empty (hungry state). If we overfill the tank (gut) beyond its capacity, it leads to engine dysfunction (agni vaishamya). Likewise, when there is excess body fluid (kleda) formation, aap bhutagni becomes less. In this condition, the diet control and medicines advised should work on aap mahabhutaagni. The water intake must be restricted. The astringent medicines should be given as they have kledashoshana (drying) and [[stambhana]] (obstructing) property.

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