Practitioners

Dr.Abhishek Lulla BAMS.M.D
AN OPEN PARALLEL COMPARATIVE RANDOMIZED PRAGMATIC CLINICAL TRIAL EVALUATING THE EFFICACY OF VIRECHANA IN STHAULYA
Lulla Abhishek1 , Acharya Shrinivasa2
Introduction

Overweight and obesity have reached epidemic proportions in India in the 21st century affecting 5% of country’s population. 1 Sthula purusha is listed as one among the astha nindita purusha2 and the cardinal symptoms of Sthaulya are Medomamsa ativruddhi, Chalasphik, Chalaudara, Chalastana, Ayathaopachaya and Anutsaha. It is said that Sthaulya may lead to a plethora of chronic lingering and fatal diseases. Parallel to this overweight (if BMI=25.0-29.9 kg/m2) and obesity (if BMI>or=30 kg/m2), are stated in the biomedicine3. Obesity is a medical condition in which excess of body fat has accumulated to such an extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems. Obesity increases the likelihood of various diseases, particularly heart disease, type 2 diabetes, breathing difficulties and osteoarthritis and so on. Though Sthaulya is a Dushya dominant disorder, in pathogenesis of Sthaulya, all the three Dosha are vitiated. The aim of treating Sthaulya is at reducing Vata, Agni and Meda. Since Sthaulya is a santarpanotha vyadhi the main line of treatment has to be apatarpana and it is best treated by shodhana procedures like Virechana karma and Lekhana basti4. It can also be treated by using Apatarpana Dravya with Guruguna.

Methods
Objectives of the study were to evaluate the therapeutic efficacy of Virechana Karma in Sthaulya, to evaluate the therapeutic efficacy of Trayushnadya loha in Sthaulya and to compare the therapeutic effects between the groups. This was an open parallel comparative randomized pragmatic clinical study where 30 patients diagnosed as sthaulya were taken from S.D.M. Ayurveda Hospital, Udupi.
Patients having symptoms and signs of sthaulya, having a BMI>25 who were in the age group of 16 – 60yr were included in the study. Subjects who were suffering from endocrinal diseases , psychiatric illness, primary systemic diseases like Hypertension, pregnant and lactating mothers were excluded. Weight, BMI, Lipid profile levels, body measurements taken at various levels (Chest, abdomen, hip, mid-arm, mid calf and mid- thigh), anthropometrics features and Percent body fat were assessed
The selected patients were randomly grouped into 2 group by adapting the permutated block randomization technique. The first group (Group A) was the Virechana group. Here initially rookshana karma was done by administering triphala choornam – 5 gm t.i.d for 3 days. Then deepana, pachana was done with Panchakola phanta 50 ml t.i.d (AC) for 3 days , followed by Snehapana with guggulu tiktaka ghrita for 4 -7 days. Finally Snigdha udwartana with tila taila and anagni sveda was done for 4 days before administering Virechana karma. Which was done by administering 12 – 24 g of trivrit choorna, taken along with madhu, ghrita and sita5,6,7. In the second Group (Group B) Trayushnadya loha8 was given at a dose of 4 tablets of 250 mg each, b.i.d . The duration of clinical trial was maximum of 24 days in first group and 30 days in the second .
Observation & Results:
Snehapana was given for a minimum of 3 days and maximum of 5 days. On an average it was given for 4.266 days. In totality most of the patients (53.33%) were given sneha pana in the amount between 500 – 599 ml, with an average of 571 ml. Most of the patients (66.66%) had madhyama shuddhi and had 19. 6 vega on an average.
In Group A, It was noticed that there was a 5.70 % reduction in weight and a reduction in BMI by 5.64% which were statistically highly significant. S.Cholesterol was reduced by 7.49 %, S.Triglyceride by 21.47 %, which were both statistically highly significant, LDL was reduced by 7.52 %, and VLDL was reduced by 39.70 %. The treatment showed a decrease in values in various body circumferences and skin fold thickness. There was also a 7.77 % reduction in Percent body-fat.
In Group B, there was a marked reduction in the weight by 2.93 % and BMI by 3.67% which were statistically highly significant.It was noticed that S.Cholesterol was reduced by 5.54%, S.Triglyceride was reduced by 2.68% , LDL was reduced by 5.34% ,VLDL was reduced by 15.76%. The treatment showed a decrease in values in various body circumferences and skin fold thickness. 5.54 % reduction in Percent body-was also noted.
Comparison between the groups shows that that the weight loss and the reduction in BMI observed after the course of virechana karma is greater than that observed after the use of Trayushnadya loha . It is noted that the after the course of virechana karma, there is a greater reduction in the values of S.Cholesterol, Triglycerides, LDL and VLDL and there is a greater increase in the value of HDL. There is also a greater reduction in the values of the body circumferences and Percent body-fat.
Discussion:
During the process of snehapana, since the person takes only ghrita and a very small quantity of food, there is acceleration of fat utilization for energy, in the absence of carbohydrates. Thus snehapana has an apatarpana effect on the body. The average routine consumption of a person per day is about 2300 calories, while in snehapna the maximum consumption was reduced to 1750 calories, thus causing a negative energy balance. Snigdha udvatana causes the increase in the lymphatic drainage. It has been proved that lymphatic massage aids in water loss, and thus ultimately weight loss. Vyayama is an anagni sweda which causes hemo-concentration. For the purpose of shodhana chikitsa, the secretory action of the mucous membrane is exploited and the body fluids are influenced for therapeutic purposes. Thus virechana is targeted at to create a biochemical alteration as it modulates the fluid compartments of the body 9,10
Trayushnadya loha contains drugs which mostly have ushna virya and laghu, ruksha guna, which are exactly opposite to the guna of Kapha and Medodhatu. Thus it is kapha-medohara. The karma of most of the drugs are dipana, pachana, vatanulomana, balya and Medoroghna. Loha being the main ingredient here acts in two ways. Firstly when given before food, it controls the appetite and as a result there is a reduction in food consumption. Secondly it causes lipid peroxidation. The four different lavana used in this medicine effect the lipid emulsification, due to the electrostatic interactions between sodium ions and lipid particles11. As a result there is reduced absorption of fats following digestion of food.
Conclusion:
The study showed that in both the groups there was a statistically highly significant improvement in the weight and BMI. After Virechana the lipids were all greatly reduced and these results were all statistically highly significant. Virechana is beneficial in Sthaulya as it helps to initiate the weight loss mechanism in the body. It also helps to check the future complications in the healthy obese. Hence Virechana is found to be effective in the management of Sthaulya.

1. Kasper, Braunwald, Fauci, Hauser, Longo, Jameson ,Harrison’s Principles of Internal Medicine- Volume I ,17th edition, McGraw-Hill Book Co-Singapore for manufacture and export pp2703, pg no. 463
2. Agnivesha, Charaka Samhita, redacted by charaka and Dridhabala, Ayurvedadipika commentary of Chakrapanidatta, edited by Trikamji Jadavji, Varanasi, Chaukhambha surbharati prakashan,2008, Pp : 738, Page no.116.
3. Haslam DW, James WP (2005). “Obesity”. Lancet366 (9492): 1197–209, available from http://www.ncbi.nlm.nih.gov/pubmed/16198769
4. Agnivesha, Charaka Samhita, redacted by charaka and Dridhabala, Ayurvedadipika commentary of Chakrapanidatta, edited by Trikamji Jadavji, Varanasi, Chaukhambha surbharati prakashan, 2008, Pp : 738 , Page no.117
5. Vagbhata, Ashtanga hrudayam,commentaries of Sarvangasundari of Arunadatta and Ayurvedrasayana of Hemadri, edited by Paradakara Hari Sadashiv Shastri, Varanasi, Chaukhambha Surbharti Prakashan, 2007, Pp :956 , Page no.251
6. Vagbhata, Ashtanga hrudayam,commentaries of Sarvangasundari of Arunadatta and Ayurvedrasayana of Hemadri, edited by Paradakara Hari Sadashiv Shastri, Varanasi, Chaukhambha Surbharti Prakashan, 2007, Pp :956 , Page no.27
7. Vagbhata, Ashtanga hrudayam,commentaries of Sarvangasundari of Arunadatta and Ayurvedrasayana of Hemadri, edited by Paradakara Hari Sadashiv Shastri, Varanasi, Chaukhambha Surbharti Prakashan, 2007, Pp :956 , Page no.28
8. Yoga ratnakar , vaidyaprabha hindi commentary , edited by Tripathi Indradev and Tripathi Dayashankar , Varanasi , Chaukhambha publication,1st edition ,1998, Pp: 894, Page no 543
9. Sushruta: Sushruta samhita: Edited by Acharya Yadavji Trikamji, Choukambha publication,Varanasi, 2000 pp.824. page number 507
10. Agnivesha, Charaka Samhita, redacted by charaka and Dridhabala, Ayurvedadipika commentary of Chakrapanidatta, edited by Trikamji Jadavji, Varanasi, Chaukhambha surbharati prakashan, 2008, Pp : 738 , Page no.704
11. S.J Hur, S.T. Joo, B.O Lim, Impact of salt and lipid type on in vitro Digestion of Emulsified Lipids, Journal of food chemistry, Published online ahead of print.

1. Kasper, Braunwald, Fauci, Hauser, Longo, Jameson ,Harrison’s Principles of Internal Medicine- Volume I ,17th edition, McGraw-Hill Book Co-Singapore for manufacture and export pp2703, pg no. 463
2. Agnivesha, Charaka Samhita, redacted by charaka and Dridhabala, Ayurvedadipika commentary of Chakrapanidatta, edited by Trikamji Jadavji, Varanasi, Chaukhambha surbharati prakashan,2008, Pp : 738, Page no.116.
3. Haslam DW, James WP (2005). “Obesity”. Lancet366 (9492): 1197–209, available from http://www.ncbi.nlm.nih.gov/pubmed/16198769
4. Agnivesha, Charaka Samhita, redacted by charaka and Dridhabala, Ayurvedadipika commentary of Chakrapanidatta, edited by Trikamji Jadavji, Varanasi, Chaukhambha surbharati prakashan, 2008, Pp : 738 , Page no.117
5. Vagbhata, Ashtanga hrudayam,commentaries of Sarvangasundari of Arunadatta and Ayurvedrasayana of Hemadri, edited by Paradakara Hari Sadashiv Shastri, Varanasi, Chaukhambha Surbharti Prakashan, 2007, Pp :956 , Page no.251
6. Vagbhata, Ashtanga hrudayam,commentaries of Sarvangasundari of Arunadatta and Ayurvedrasayana of Hemadri, edited by Paradakara Hari Sadashiv Shastri, Varanasi, Chaukhambha Surbharti Prakashan, 2007, Pp :956 , Page no.27
7. Vagbhata, Ashtanga hrudayam,commentaries of Sarvangasundari of Arunadatta and Ayurvedrasayana of Hemadri, edited by Paradakara Hari Sadashiv Shastri, Varanasi, Chaukhambha Surbharti Prakashan, 2007, Pp :956 , Page no.28
8. Yoga ratnakar , vaidyaprabha hindi commentary , edited by Tripathi Indradev and Tripathi Dayashankar , Varanasi , Chaukhambha publication,1st edition ,1998, Pp: 894, Page no 543
9. Sushruta: Sushruta samhita: Edited by Acharya Yadavji Trikamji, Choukambha publication,Varanasi, 2000 pp.824. page number 507
10. Agnivesha, Charaka Samhita, redacted by charaka and Dridhabala, Ayurvedadipika commentary of Chakrapanidatta, edited by Trikamji Jadavji, Varanasi, Chaukhambha surbharati prakashan, 2008, Pp : 738 , Page no.704
11. S.J Hur, S.T. Joo, B.O Lim, Impact of salt and lipid type on in vitro Digestion of Emulsified Lipids, Journal of food chemistry, Published online ahead of print.