Ayurvedic intervention with Pachana Aushadhi and Lekhan Basti in Obesity: A case study

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Introduction
The Charaka Samhita identifies eight categories of undesirable conditions known as Nindita purusha, with Athisthaulya being one of them.[1] Athisthaulya can be associated with obesity, characterized by an excessive accumulation of fat in adipose tissues.Obesity, a chronic and widespread abnormal metabolic condition, impacts millions of individuals globally.Projections indicate that by the year 2030, approximately 1.12 billion adults will fall under the category of obesity, and 2.16 billion will be classified as overweight worldwide.[2] In recent years, there has been a significant upswing in the prevalence of lifestyle disorders.With a population of 300 million, the adoption of unhealthy habits such as consuming junk food and alcohol has become a prevailing trend across all age groups.Factors such as a sedentary lifestyle due to remote work and the pervasive stress following the COVID-19 epidemic have contributed to a notable surge in Sthaulya, or obesity.[3] Obesity, characterized by a body mass index (BMI) equal to or greater than 30, is a pressing health concern.[4] In Ayurveda, obesity can be correlated with Sthoulya or Medoroga within the category of Santarpana Diseases.[5] It is considered a disorder of Medovaha strotas dushti caused by the intake of Guru (heavy), Madhur (sweet), and Snigdha (unctuous) Aahar (food).[6] Ayurvedic principles advocate three treatment approaches: Nidan parivarjana (elimination of causative factors), Shaman (pacification), and Shodhan (purification).According to Acharya Vagbhata, the line of treatment involves 'Guru cha Apatarpanam', [7] and in this case, Apatarpan chikitsa is employed to address obesity by reducing the excessive accumulation of fat.Following a comprehensive assessment, including detailed history-taking and examination, it was observed that the aetiology and symptoms of the case closely resembled Sthaulyata, as outlined in Ayurvedic texts.In the context of Sthaulya, the excess intake of food leads to the accumulation of Meda (fat) within the body.This accumulated fat, in turn, results in Margaavarana (obstruction of channels), impeding the flow of nutrition to subsequent Dhatus (tissues).This process causes the vitiation of Vata, which then travels through the Kostha (digestive tract), stimulating Agni (appetite).The heightened appetite prompts the individual to consume more food, leading to a further buildup of Meda (fat) in the body, ultimately culminating in the manifestation of Sthaulya (obesity).[8] Therefore, Sthaulya (Obesity) can be perceived as a condition arising from the obstruction caused by the excessive accumulation of fat due to an imbalanced nourishment process, rooted in Medoja (fat-based) factors.
After initiating the treatment, the patient exhibited a positive response within a short period.This encouraging outcome prompted us to document the case comprehensively, to further its potential application in the treatment of similar cases.

Patient information 2.1. Case Report
On May 10, 2023, a 52-year-old female patient presented at the Kayachikitsa outpatient department (OPD) with a medical history spanning 3-4 years of increased body weight, Kshudra shwas (dyspnea), Daurbalya (weakness), and Sandhishool (pain in both knee joints) persisting for the last 3 months.Additionally, she reported experiencing Atitrushna (excessive thirst), Atikshudha (excessive hunger), and Swedabadh (excessive sweating) over the past year.
Remarkably, the patient exhibited almost all of the eight symptoms of Atisthula, as elucidated by Acharya Charak.[9] This comprehensive set of symptoms leads to the diagnosis of Sthaulya.

History of personal illness
The patient was normal 3 years ago, but gradually developed all the above symptoms which increased in 3 months.Thus, to overcome this she came to our hospital for treatment.

History of other illnesses
The patient had no other major illnesses like DM, HTN, Hyperthyroidism, or PCOS.

Samprapti Ghatak (Pathogenic Factors)
The following factors play a major role in the samprapti of Sthaulya.

Figure 1 Samprapti of Sthaulya
Table 1 represents the timeline of the occurrence of events in the present case study.It represents all the symptoms along with the previous treatment taken by the patient and the results obtained.

Table 1 Timeline December 2018
In 2018, the patient lost her job, leading to a sedentary lifestyle and weight gain.; being stressed about it she joined a gym.

May 2019
She started getting cramps while gyming thus she left and went for a nutrition course, there along with nutritional shakes some exertional dance exercise was started.Here she lost 4-5 kg.weight.

2020
In Jan 2020, she got a skin reaction of hypopigmentation on both her upper and lower extremities and consulted a dermatologist who suggested her to stop nutrition supplements.Thus she stopped that course and consulted a naturopath centre in badlapur, by then she had regained the lost weight.

2021
She was admitted to that naturopath foundation for 8 days from June 8 to June 15 and was discharged with 3 kg weight loss and medicinal tablets for further reduction of weight.Later she found no results thus the treatment was stopped on 20 July 2021.

2022
Being fed up with all the treatment patient didn't take any treatment from 20 July 2021 to 9 May 2023 and had a major weight gain of 12-13 kgs.The proposed treatment regimen consisted of:

Observation and Results
Following a 30-day treatment regimen, notable improvements were observed in the signs and symptoms of Sthaulya.Clinical examination indicated enhancements in both subjective and objective parameters, reflecting the effectiveness of the treatment.[as shown in

Results
Upon initial consultation, the patient presented with a weight of 112 kg, which subsequently decreased to 101 kg throughout 6 follow-up sessions.This represents a significant reduction of 11 kg in weight within 30 days, accompanied by observable fat reduction.
The patient's Body Mass Index (BMI) decreased from 41.1 to 37.1, indicating a substantial improvement in body composition and weight management.
Udvartana [18] involves the application of herbal powders across the body, facilitating the breakdown and elimination of fat.
Koshna Siddha Jalpana [19] refers to the consumption of warm water infused with Kledaghna and Lekhana Dravya, aiding in the combustion of excess fats and promoting Pachana (digestion).

Shaman aushadi
Trishila guggul [20] composed of Triphala, Shilajit, and guggul, has demonstrated efficacy in reducing fat accumulation and consequently aiding in weight loss.
Aamapchaka vati, formulated with Sunth, Ativisha, and Musta, exhibits Dipana and Pachana properties.These attributes contribute to increasing Agni (digestive power) and facilitating the digestion of undigested food (Ama).[22] According to Ayurveda, the patient was diagnosed with Sthaulya characterized by an imbalance of Kapha and Vata doshas, as well as impairment of the Medovaha srotas and disturbances in the Rasa, Mansa, and Meda dhatus.The patient's sedentary lifestyle, consumption of heavy, sweet, and oily foods, along with lack of exercise and poor dietary habits contributed to this condition.
Clinically, the patient presented with increased body weight (Sphik stan udar lambanam), fatigue, and bilateral knee joint pain.Following the principles of Santarpana samprapti the treatment approach primarily focused on Apatarpan chikitsa aiming at reducing excess body fat.This included therapies such as Lekhan basti and udvartana, along with Shaman and lekhan medicines.Significant improvements were observed, prompting the patient to continue the prescribed treatment regimen along with Siddha jalapana and Udvartana.A follow-up appointment was recommended to monitor progress and make further adjustments as needed.

Conclusion
In conclusion, the lifestyle disorder Sthaulya, or obesity, is effectively managed through a combination of lifestyle modifications, internal medications, and Panchakarma therapies in Ayurveda.Recognized as a Santarpanjanya roga, Sthaulya necessitates the Apatarpana approach, focusing on the reduction and elimination of excess adipose tissue.Lifestyle modifications entail Nidan parivarjana, avoiding factors that aggravate Rasa dhatu, Meda dhatu, and Kapha dosha.Internal medications target the reduction of Kleda, or excessive moisture, within the body.Panchakarma treatments involve procedures akin to Apatarpana to facilitate weight loss.
In the presented case study, interventions such as Sarvanga Udvartana (herbal powder massage), Bashpa swedan (herbal steam therapy), Lekhan basti (medicated enema for scraping off excess fat), Shaman aushadi (medicinal therapy for balancing doshas), along with dietary modifications were employed.These interventions resulted in significant weight reduction for the patient, demonstrating effective management of the eight Mahadosh associated with obesity.

Disclosure of conflict of interest
No conflict of interest to be disclosed.

Table 2
Treatment Schedule  Siddha jala -A decoction prepared by boiling equal quantities of Trifala, Musta, and Vidanga with water until it reduces to half. Udvartana -Application of a powder mixture consisting of Triphala, Musta, Sarshap, and Yava on alternate

Table 5
Objective Assessment

Table 6
Mode of action of all ingredients of Basti