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=== Introduction ===

=== Introduction ===

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Charak has laid down the foundation of genetic/hereditary and endocrinal disorders in relation to four pairs of opposing (and undesirable) physical characteristics- height (too tall, too short), body hair (too hairy, hairless), complexion (too dark, too light), and body mass (too obese, too lean). Among these, ''atisthula'' (morbid obesity) is the most undesirable characteristic because it is associated with several life-threatening complications including diabetes, hypertension, coronary artery diseases, joint disorders, skin disorders, anorectal problems, etc. This chapter focuses on the features of a healthy physical constitution of a person, definitions of sleep, as well as key concepts associated with disease management such as etiopathogenesis, clinical presentation, prognosis, and management of ''atisthula''. Some key etiological factors of ''atisthula'' include dietary and lifestyle indicators (e.g., sedentary habit and high-calorie diet), and genetic and hereditary factors. This chapter also describes the pathogenesis of ''atisthula'' in detail, involving ''rasa'' (plasma) and ''meda'' (adipose tissue) as important ''dushyas'' (affected tissues). Modern medicine has acknowledged the role of ''meda'' (adipose tissue) as a principal ''dushya'', with  obesity and dyslipidemia regarded as the main components of the basic matrix of this disease and its related disorders<ref name=ref1>Pandey A. K and Singh R. H.:  “A Study of the Immune status in patients of diabetes mellitus and their Management with certain NaimittikaRasayana drugs”, JRAS. Vol. XXIV. No. 3-4, 2003; 48-61. </ref>  <ref name=ref2>Pandey A.K and Singh R.H. (2012): A Clinical Study on Certain Diabetic Complications under the Influence of Naimittika Rasayana Therapy w.s.r. to Nishamalaki and Shilajatu), PhD. Thesis, Department of Kayachikitsa,, IMS, BHU, Varanasi. </ref> <ref name=ref3>Jaspreet Singh & A. K. Pandey: Clinical Evaluation of Pushkaramula (Inula racemosa) Capsule in the patients of Metabolic syndrome”, International Journal of Medicine and Pharmaceutical Sciences (IJMPS), ISSN(P): 2250-0049; ISSN(E): 2321-0095, Vol. 4, Issue 2, Apr 2014, 9-20. </ref>. The recent concept of “metabolic syndrome” was already recognized in Ayurveda. Biomedical science points that overweight individuals experience greatly elevated morbidity and mortality from various ailments including cardiovascular diseases<ref>National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. Bethesda, Md: National Heart, Lung, and Blood Institute and National Institute of Diabetes and Digestive and Kidney Diseases; 1998. </ref> <ref>Alpert MA. Obesity cardiomyopathy: pathophysiology and evolution of the clinical syndrome. Am J Med Sci. 2001;321: 225–236. </ref>

Charak has laid down the foundation of genetic/hereditary and endocrinal disorders in relation to four pairs of opposing (and undesirable) physical characteristics- height (too tall, too short), body hair (too hairy, hairless), complexion (too dark, too light), and body mass (too obese, too lean). Among these, ''atisthula'' (morbid obesity) is the most undesirable characteristic because it is associated with several life-threatening complications including diabetes, hypertension, coronary artery diseases, joint disorders, skin disorders, anorectal problems, etc. This chapter focuses on the features of a healthy physical constitution of a person, definitions of sleep, as well as key concepts associated with disease management such as etiopathogenesis, clinical presentation, prognosis, and management of ''atisthula''. Some key etiological factors of ''atisthula'' include dietary and lifestyle indicators (e.g., sedentary habit and high-calorie diet), and genetic and hereditary factors. This chapter also describes the pathogenesis of ''atisthula'' in detail, involving ''rasa'' (plasma) and ''meda'' (adipose tissue) as important ''dushyas'' (affected tissues). Modern medicine has acknowledged the role of ''meda'' (adipose tissue) as a principal ''dushya'', with  obesity and dyslipidemia regarded as the main components of the basic matrix of this disease and its related disorders<ref name=ref1>Pandey A. K and Singh R. H.:  “A Study of the Immune status in patients of diabetes mellitus and their Management with certain NaimittikaRasayana drugs”, JRAS. Vol. XXIV. No. 3-4, 2003; 48-61. </ref>  <ref name=ref2>Pandey A.K and Singh R.H. (2012): A Clinical Study on Certain Diabetic Complications under the Influence of Naimittika Rasayana Therapy w.s.r. to Nishamalaki and Shilajatu), PhD. Thesis, Department of Kayachikitsa,, IMS, BHU, Varanasi. </ref> <ref name=ref3>Jaspreet Singh & A. K. Pandey: Clinical Evaluation of Pushkaramula (Inula racemosa) Capsule in the patients of Metabolic syndrome”, International Journal of Medicine and Pharmaceutical Sciences (IJMPS), ISSN(P): 2250-0049; ISSN(E): 2321-0095, Vol. 4, Issue 2, Apr 2014, 9-20. </ref>. The recent concept of “metabolic syndrome” was already recognized in Ayurveda. Biomedical science points that overweight individuals experience greatly elevated morbidity and mortality from various ailments including cardiovascular diseases<ref>National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. Bethesda, Md: National Heart, Lung, and Blood Institute and National Institute of Diabetes and Digestive and Kidney Diseases; 1998. </ref> <ref>Alpert MA. Obesity cardiomyopathy: pathophysiology and evolution of the clinical syndrome. Am J Med Sci. 2001;321: 225–236.</ref>

    

    

Obesity research is focused on preventive measures and management of complications like prediabetes, diabetes, metabolic syndrome, hypertension, stroke, coronary heart disease, congestive heart failure, cardiomyopathy, and arrhythmia/sudden death<ref>Singh Jaspreet & Pandey A.K. (2012): Clinical Evaluation of Pushkarmula churna in the patients of metabolic syndrome w.s.r, to Ojas and Agni MD (Ay) Department of Kayachikitsa, IMS, BHU, Varanasi. </ref>. In the modern world, obesity has emerged as a serious health issue in both developed and developing nations and is recognized as one of the most serious public health problems of the 21st century. In 2008 the WHO estimated that globally, at least 500 million adults (or approximately 1 in 10 adults) are obese, with higher rates among women than men. Obesity is the reason for about 80% of type 2 diabetes, about 70% of cardiovascular diseases, and 42% of breast and colon cancers today. In the past two decades, the number of overweight children and adolescents has doubled<ref>Lau D.C. et al (April 2007). "2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]", CMAJ , 176 (8): S1–13. </ref>. The rate of obesity also increases with age at least up to 50 or 60 years old. Once considered a problem specific to only high-income countries, obesity has acquired pandemic proportions and is affecting people globally<ref>World Health Organization (WHO) (2000). Obesity: Preventing and Managing the Global Epidemic. Report on a WHO Consultation. Geneva. (WHO technical report series 894). </ref> <ref>P.J.English, M.A.Ghatei, I.A.Malik, S. R. Bloom and J. P. H. Wilding ( June-1, 2002): Food fails to suppress ghrelin levels in obese humans, The Journal of Clinical Endocrinology & Metabolism, 87(6):2984–2987. </ref>.

Obesity research is focused on preventive measures and management of complications like prediabetes, diabetes, metabolic syndrome, hypertension, stroke, coronary heart disease, congestive heart failure, cardiomyopathy, and arrhythmia/sudden death<ref>Singh Jaspreet & Pandey A.K. (2012): Clinical Evaluation of Pushkarmula churna in the patients of metabolic syndrome w.s.r, to Ojas and Agni MD (Ay) Department of Kayachikitsa, IMS, BHU, Varanasi. </ref>. In the modern world, obesity has emerged as a serious health issue in both developed and developing nations and is recognized as one of the most serious public health problems of the 21st century. In 2008 the WHO estimated that globally, at least 500 million adults (or approximately 1 in 10 adults) are obese, with higher rates among women than men. Obesity is the reason for about 80% of type 2 diabetes, about 70% of cardiovascular diseases, and 42% of breast and colon cancers today. In the past two decades, the number of overweight children and adolescents has doubled<ref>Lau D.C. et al (April 2007). "2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]", CMAJ , 176 (8): S1–13. </ref>. The rate of obesity also increases with age at least up to 50 or 60 years old. Once considered a problem specific to only high-income countries, obesity has acquired pandemic proportions and is affecting people globally<ref>World Health Organization (WHO) (2000). Obesity: Preventing and Managing the Global Epidemic. Report on a WHO Consultation. Geneva. (WHO technical report series 894). </ref> <ref>P.J.English, M.A.Ghatei, I.A.Malik, S. R. Bloom and J. P. H. Wilding ( June-1, 2002): Food fails to suppress ghrelin levels in obese humans, The Journal of Clinical Endocrinology & Metabolism, 87(6):2984–2987. </ref>, <ref>Pandey, A. K. (2015): </ref>

 

<ref>Pandey, A. K. (2015): </ref>Any course of treatment for obesity suggested by modern medical practitioners primarily includes dietary changes and physical exercise followed by anti-obesity drugs that help reduce appetite or inhibit fat absorption. In severe cases, various invasive and non-invasive surgical procedures could be prescribed - such as partial gastrectomy, gastric bypass, banding, gastric balloons, etc<ref>Puhl R, Brownell KD (December 2001): "Bias, discrimination, and obesity". Obes. Res.9 (12): 788–805. doi:10.1038/oby.2001.108. PMID 11743063. </ref>. However, Ayurveda’s approach to weight management is very different in that it does not recommend pills or surgeries for inducing drastic weight-loss. Instead, Ayurveda advocates dietary restrictions according to the ''prakriti'' (predisposition or temperament of the patient), moderate exercise, practice of ''yogasanas'' and ''pranayama'', besides certain ayurvedic medications and bio-purificatory measures for its management<ref>Pandey A.K. (2013-2014): Conceptual background on obesity (sthaulya/medoroga) & an approach for its management through ayurveda, chapter published in a book ‘Integrative approach to metabolic syndrome’ published by Mahima research foundation and social welfare, Varanasi, UP, India, 2013-2014, p.no.-47-59. </ref>.

Any course of treatment for obesity suggested by modern medical practitioners primarily includes dietary changes and physical exercise followed by anti-obesity drugs that help reduce appetite or inhibit fat absorption. In severe cases, various invasive and non-invasive surgical procedures could be prescribed - such as partial gastrectomy, gastric bypass, banding, gastric balloons, etc<ref>Puhl R, Brownell KD (December 2001): "Bias, discrimination, and obesity". Obes. Res.9 (12): 788–805. doi:10.1038/oby.2001.108. PMID 11743063. </ref>. However, Ayurveda’s approach to weight management is very different in that it does not recommend pills or surgeries for inducing drastic weight-loss. Instead, Ayurveda advocates dietary restrictions according to the ''prakriti'' (predisposition or temperament of the patient), moderate exercise, practice of ''yogasanas'' and ''pranayama'', besides certain ayurvedic medications and bio-purificatory measures for its management<ref>Pandey A.K. (2013-2014): Conceptual background on obesity (sthaulya/medoroga) & an approach for its management through ayurveda, chapter published in a book ‘Integrative approach to metabolic syndrome’ published by Mahima research foundation and social welfare, Varanasi, UP, India, 2013-2014, p.no.-47-59. </ref>.

The etiology, pathogenesis, clinical features and consequences of extreme leanness (''atikrisha''), as an outcome of ''rasakshaya'' (decrease of ''rasa''), ''medokshaya'' (decrease of ''meda'') and ''mamsakshaya'' (decrease of ''mamsa'') have also been described in this chapter. The two basic approaches for management of ''atikrisha'' and ''atisthula'' are augmentation (''brimhana'') and depletion (''karshana'') of body tissues respectively. Various drug and non-drug modalities have been suggested for the replenishment of ''dhatus'' and their nourishment to attain good health. In this regard, ''Rasayana'' drugs of Ayurveda help balance hormones, promote essential nutrition and enhance immunity to ''atisthula'' and ''atikrisha'' respectively. As mentioned earlier, this chapter also emphasizes the role of good ''nidra'' (sleep) in maintaining a healthy life. In fact, as per Ayurveda, after ''ahara'' (diet), ''nidra'' is one of the three sub-pillars of life (''trayopastambha'') and has a significant place in preventive medicine because normal sleep helps prevent diseases and unwholesome sleep may lead to fatal diseases. In Ayurveda, ''nidra'' is considered a ''brimhana'' (nourishing) agent that promotes physical and mental health and enhances immunity<ref>Vd. H.S.KHushvaha (2009). Agniveshakrita Charak Samhita, Sutrasthana-11, Varanasi, Chaukhambha Orientalia, 2009.  </ref>.

The etiology, pathogenesis, clinical features and consequences of extreme leanness (''atikrisha''), as an outcome of ''rasakshaya'' (decrease of ''rasa''), ''medokshaya'' (decrease of ''meda'') and ''mamsakshaya'' (decrease of ''mamsa'') have also been described in this chapter. The two basic approaches for management of ''atikrisha'' and ''atisthula'' are augmentation (''brimhana'') and depletion (''karshana'') of body tissues respectively. Various drug and non-drug modalities have been suggested for the replenishment of ''dhatus'' and their nourishment to attain good health. In this regard, ''Rasayana'' drugs of Ayurveda help balance hormones, promote essential nutrition and enhance immunity to ''atisthula'' and ''atikrisha'' respectively. As mentioned earlier, this chapter also emphasizes the role of good ''nidra'' (sleep) in maintaining a healthy life. In fact, as per Ayurveda, after ''ahara'' (diet), ''nidra'' is one of the three sub-pillars of life (''trayopastambha'') and has a significant place in preventive medicine because normal sleep helps prevent diseases and unwholesome sleep may lead to fatal diseases. In Ayurveda, ''nidra'' is considered a ''brimhana'' (nourishing) agent that promotes physical and mental health and enhances immunity<ref>Vd. H.S.KHushvaha (2009). Agniveshakrita Charak Samhita, Sutrasthana-11, Varanasi, Chaukhambha Orientalia, 2009.  </ref>.