Words: Drs Sidram GULED & Jyoti
Sthoulya [obesity] is not only a disease; it is a phenotype, a disease manifestation, that is difficult for management.
Patients of COVID-19, with associated obesity, to pick a recent example, had higher rates of hospital admission, need for oxygen, more ICU admissions and higher rates of mortality. When sthoulya becomes atisthoulya [over-obese] an array of pathological changes manifest; they lead to several upachayaja [metabolic diseases, like type-2 diabetes] and vatavarodhaja [occlusion, or obstruction, or overaccumulation]. This, in turn, leads to vata margavarana, causing vatavyadhi-like cardiovascular diseases, stroke, cancer and other diseases. It reduces life expectancy and destroys the whole body, like a little fire destroys the whole forest with the support of gusty wind.
Sthoulya is the pendulous deposition of meda in udara [abdomen], sthana [chest] and sphik [gluteal region]. This triggers central obesity with clinical implications other than peripheral obesity. Imbalance in upachaya of dhatus [excess fat and compromised other tissues], avarana of vata by meda and kapha in different areas of shareera and errors in hunger and food intake are the key factors in the pathology of diseases occurring in sthoulya.
New research has suggested that, over 1.9 billion population of middle age are overweight and 650 million are suffering from obesity worldwide. In India, over 135 million people have obesity. Occurrence rates of obesity in India alters, primarily because of age, sex, environment, social and economic factors. A recent study by the Indian Council of Medical Research in 2015 [ICMR-INDIAB] says that [in India], obesity and abdominal obesity range accordingly between 11.8 per cent and 31.3 per cent and 16.9 per cent and 36.3 per cent, respectively. Central obesity is one among the important risk factors for vascular diseases of heart [CVDs] and a major cause of mortality in India.
Definition
Obesity is characterised by the excessive increase in meda and mamsa dhatu [compared to other dhatus], bulky and pendulous chest, gluteal and abdomen area as a result of unequal nourishment of body [excessive meda and less other dhatus]. This leads to loss of body strength, although the person who looks stout is called as sthoulya.
The Ayurveda Perspective
Ayurveda delineates obesity not merely by, or on, weight, or BMI, but physical signs — viz., unequal nourishment of dhatus [excess meda and mamsa and less of other dhatus] that ultimately lead to bala kshaya [body strength]. The obese individual becomes exhausted with little work, or exercise. They will be unable to perform moderate daily physical activities with ease. This unequal ‘balance,’ also nourishment, is a major sign of atisthoulya, which is a dosha that can have health consequences. Those who are not over-obese and don’t have loss of strength will not have serious health consequences of sthoulya. This means a person looking obese, but carries out moderate to regular daily activities with ease may not need rigorous weight reduction modalities as long as they are fit by such activities.
Another important physical sign that indicates sthoulya is excess deposition of meda and mamsa [fat and muscle] in chest, belly and gluteal [central obesity]; they will look flabby and pendulous. Such persons will be having health consequences much more than those having equally distributed fat all over the body and compactness of fat and muscle [samhananata].
Recent studies classify obese into two, viz., metabolically healthy obese and metabolically unhealthy obese [MHO and MUHO]. The total amount of fat in the body is not the only key reason that describes obese population metabolically at risk. Site of accumulation of excessive adipose tissue and its altered activity will decide the metabolic health of an individual. Deposition of excessive adipose mass in abdomen and chest is the major reason for development of complications of obesity and also mortality. Another group of population having obesity, called as metabolically healthy obese [MHO] people, are comparatively safe from the manifestation of metabolic diseases of the heart than those of metabolically unhealthy obese population. Subjects who are metabolically unhealthy obese have less subcutaneous adipose tissue, hypertrophy of adipocytes, higher inflammatory response of adipose mass and changed storage capacity of adipocytes that result in internal accumulation of fat [i.e., higher fat in viscera, deposition of lipids in hepatic tissues and skeletal muscles] and raised inflammatory response in adipose cells, leading to insulin resistance and chronic metabolic conditions of heart.
Astha Dosha Of Sthoulya
Acharya Charaka says sthoulya is not a nindita, but atisthoulya [over-obese] is nindita that may have doshas. Atisthula person may have health issues rather than one who is merely sthula.
अतिस्थूलस्य िावदायुषो ह्रासो जवोपरोधः कृ च्छ्र व्यवायिा दौर्बल्यं दौर्बन्ध्यं स्वेदार्ा धः क्षुदतिमात्रं तपपासातियोर्श्चेति भवन्त्यष्टौ दोषाः ||
Common health issues that the obese person is going to suffer in their lifetime are called sthoulya dosha.
Ayu Kshaya: Reduced Lifespan
Disturbed nourishment in obesity causes the fat tissues to nourish and deposit in excess compared to other tissues. This disproportionate nourishment of tissues leads to meda santarpana janya vyadhi, like prameha and margavarana janya vyadhi, like vatavyadhi, will result in ayu kshaya due to early morbidity and mortality.
Obese individuals may die early, develop many complications and suffer with cardiovascular disorders, raised blood pressure, cerebrovascular accidents, insulin-dependent diabetes mellitus, insulin-resistance syndrome and also impaired mental status. Charaka says that sthula will suffer with one, or other dharuna [serious/acute life threatening] vyadhi. Shivadasa Sena, a commentator of Charaka, explains serious illnesses that a sthula can suffer, like prameha, pidakas, jwara, bhagandara, vidradhi, vatavyadhi [pakshaghata, hridroga of vataja variety, etc]. Such diseases are certainly going to cause morbidity and mortality of the obese population. This means a sthula person is going to lose their life early. This is how ayu khaya is going to occur in sthula.
Javoparodha: Reduced Quickness In Activity
Meda, by the virtue of its properties like laxity, heaviness, softness and delicateness, makes a sthula person lose quickness, speed and swiftness in their physical activities. Java refers to speed, swift and quickness.
Reduced activity [contraction] of skeletal muscles leads to restricted movement; it also increases obesity linked health issues. Obesity interrupts calcium signalling and 5′-adenosine monophosphate-activated protein kinase [AMPK] functions in muscle cells. Obesity and aging have the same functional impairments of body. Elder population associated with obesity have reduced muscular functions, higher morbidity and deaths.
Krichra Vyavaya: Loss Of Libido & Infertility
Reduced shukra dhatu production [low sperm count and hypogonadism] due impaired nourishment of shikra dhatu and obstruction by meda to shukra will result in difficulties with sexual life and infertility [erectile dysfunction of atherogenic origin]. Obesity has been reported to be associated with erectile dysfunction, low testosterone concentrations and infertility. Overweight in males is well-known for development of secondary hypogonadism. Secondary hypogonadism is associated with reduced levels of testosterone along with clinical symptomatology, viz. loss of libido and sexual performance, reduced voluntary erections, reduced body hair, especially in axilla and pubic region, loss of facial hair [beard], hampered sperm production, along with low inhibin B levels and reduced/normal follicular stimulating hormone and luteinising hormone levels. Males associated with overweight more commonly suffer with erectile dysfunction [ED]. Many research papers establish that obesity, especially abdominal obesity, is connected with atherogenic erectile dysfunction. Insulin resistance, leptin resistance, inflammatory mediators, kissprotiens are key factors resulting in hypogonadism. Fat mass present in abdomen, above the pubic region and medial aspects of thighs covering and applying pressure on scrotum causes raised temperature inside the scrotum, leading to raised DNA splitting and higher oxidative stress. The abdominal, suprapubic and medial thigh fat, wrapping the scrotum, leads to an increase in intrascrotal temperature determining increased DNA fragmentation and increased oxidative stress. This further affects reduced sperm standards; raised temperature inside scrotum impact on low sperm motility and count.
Not only men, even women of reproductive age, also suffer from infertility. In females suffering with obesity, especially those associated with abdominal obesity, the possibility of conception per cycle is low. They also suffer from disturbances in the hypothalamic-pituitary-ovarian axis, impaired menstruation cycle, and oligo-ovulation, or anovulation, three times more than non-obese individuals. Obese women with infrequent ovulation and obesity have a negative effect on the development of endometrium and attachment of fertilised egg to it. Manifestation of polycystic ovarian disease [PCOD] is common in women with obesity, so obese women with PCOD having a severe phenotype and frequently suffer subfertility. Obese women negatively respond to in vitro fertilisation [IVF], intracytoplasmic sperm injection [ICSI] and other assisted fertilisation methods.
Dourbalya: Reduced Body Strength
Loss of body strength is because of improper nourishment of all dhatus. Shivadasa Sena says bala is too low compared to size of body. Even though size of body is big, its deposit of fat is juxtaposed by less of other vital dhatus, like rasa to shukra. Charaka opined that in sthoulya only meda dhatus are nourishment-less of other dhatus resulting in bala kshaya. Bala is dependent on quantity and quality of every dhatu [mainly mamsa] and asthi dhatu which is deficient in sthoulya due to obstruction of meda to rasa and other nourishing dhatu.
Obesity reduces the muscle strength and its activities. It most likely leads to the dysfunction of muscles as also movement, power, and limits the postural and dynamic balance. There is a general agreement that subjects with obesity, without consideration of age, have higher absolute muscle power in comparison with non-obese subjects. It suggests that higher adiposity adds a long-term overload on muscles that act against gravity [e.g., quadriceps and calf], thereby expanding muscle size and power. Even though there is a greater muscle strength, it is nullified by deposited adipose mass and such subjects experience low strength. The comparative loss of strength in them is due to low mobility, neural adaptations and altered size of muscle.
Body strength is dependent on function of the musculo-skeletal system. Due to insulin resistance all tissues of the body get impaired glucose supply with impaired nourishment of tissues. This leads to reduced metabolism of glucose and energy synthesis within cells. The same mechanism is possible with musculo-skeletal tissues. A study showed that antioxidant supplementation and exercise training in patients with obesity have increased insulin sensitivity and increased uptake of glucose by muscle cells while regaining their strength.
Dourgandya: Bad Body Odour
Vitiated meda by dosha, nature of meda, and excess sweat in obesity will cause bad body odour. All the cited three causes have individual effects in bad body odour. Bad body odour is called as bromhidrosis — they are of four types, viz., eccrine, apocrine, exogenous and endogenous. Endogenous causes include systemic diseases, like overweight, type-1 and type-2 diabetes mellitus, hepatic disorders, kidney failure and dermatological diseases of palms, soles and flexures. Obesity also affects sebaceous and sweat glands and causes circulatory and lymphatic changes.
There are two additional, or conspicuous, issues in sthoulya, viz., ati kshudha, or excessive hunger, and ati pipasa, or excessive thirst — among other systemic complications.
Conclusion
Sthoulya is a phenotype; it’s not merely a disease. Asthadosha are complications of health issues associated with sthoulya. The diseases manifesting in sthoulya are going to become severe. Pathology and treatment of such diseases require special attention. Sthoulya persons having poor strength in terms of body and immunity become susceptible to infections. Pathologies in obesity like hyperlipidemia, insulin resistance, hypertension and other conditions are going to end up in dreadful cardiovascular and cerebrovascular diseases. They are the major causes of mortality. The same concept is mentioned in Ayurveda as medavruta vata — a major culprit for all the complications that sthoulya suffers from — like vatavyadhi [hridroga and pakshaghata], prameha, vandhyatwa [infertility], impaired hunger, thirst and others. It is obvious that sthoulya is a disease of concern today, primarily because of its high prevalence — thanks to our sedentary lifestyle and altered food habits. Add to it complications of obesity and severity of other diseases of infectious origin, they are a tangible cause of early mortality and reduced life expectancy.
