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A person is said to be obese when his buttocks, abdomen and breasts begin to show movement (during activity) due to accumulation of fat in these places. (1)
With the widespread recognition that overweight and obesity have reached epidemic proportions worldwide, weight loss is a significant topic to address from an Ayurvedic perspective. In Madhav Nidhan, the Ayurvedic definition of obesity is clearly and unequivocally stated. In current medical usage, the term "overweight" refers to a body mass index (BMI) of 25 through 29 and "obesity" to a BMI of 30 or more (2). IN children, obesity is defined as being on the 95th percentile or higher for weight as compared with other children of the same age and height; however, the figures are adjusted by using weights of children from the seventies, before the obesity epidemic.
According to the World Health Organization, there are more than one billion adults with overweight worldwide, of whom 300 million are obese. In the US, an estimated 400,000 deaths annually are attributed to excess weight. As reported in the lay press, an estimated 64.5 % of American adults (over 120 million people) are overweight or obese, as opposed to 45% in 1960 (3). In Mexico, over fifty percent of the adult population and nearly one third of all children suffer from overweight or obesity. (4) The global obesity epidemic has had far reaching effects. In July 2006, the Daily Mail announced that British hospitals 'had (been) forced to spend hundreds of thousands of pounds reinforcing beds and increasing mortuary space' as a result of the obesity epidemic (5). In January of 2010, Air France announced that it would charge extra to obese passengers too large to fit into a single seat. Various American airlines, such as Southwest, soon followed suit. And in February of 2010, First Lady Michelle Obama launched the "Let's Move" campaign to combat childhood obesity with better nutrition and more physical exercise.
Obesity causes or exacerbates an array of health conditions including hypertension, diabetes mellitus, sleep apnoea, back and joint problems, cardiovascular disease, Non alcoholic fatty liver disease, pseudotumor cerebri, thromboembolic disease, and others. Cancers of the breast, uterus, and colon are more common in obese subjects. (2). In the US, obesity may soon surpass smoking as the chief cause of preventable deaths. (2)
According to Madhav Nidhan, the causes of obesity are sedentary lifestyle, sleeping during the day and excess consumption of kaphagenic foods. This leads to increase of medas, which obstructs the other srotansi, depriving them of nutrition (1). The full rupa or symptom picture of obesity includes shortness of breath on mild exertion, excess thirst, delusions (perhaps due to excess blood sugar), sleepiness (possibly the result of sleep apnea), sudden catching of the breath, exhaustion, excess hunger, body odour, reduced physical capacity, loss of libido and erectile dysfunction (1). The build-up of medas obstructs vata in the abdomen, resulting in an inceased digestive activity, which leads to voracious hunger and a craving for large quantities of food (1). Thu obesity, by imbalancing metabolism, creates a positive feedback loop of spiralling weight gain. Obstructed vata fans agni like a forest fire, destroying the healthy tissues of the body, which are replaced by fat. All three doshas increase, leading to severe complications and eventual death (1).
Ayurveda and modern biomedicine have much to offer each other in terms of an in-depth understanding of overweight and obesity. The old perspective that weight gain is purely a result of consuming excess calories is now being re-thought as Western medicine wrestles with the question of why two individuals following the same diet and lifestyle can yet have different profiles in terms of weight gain. An AMA report notes, "Increasing evidence suggests that obesity is not a simple problem of willpower or self control [in eating and physical activity] but is a complex disorder involving appetite regulation and energy metabolism that is associated with a variety of co-morbid conditions." (6) Getting closer yet to an intuitive understanding of a constitutional approach through the language of 'metabolic profile,' a leading writer in the field of sports medicine notes, "Suppose, for example, that weight gain is indeed the product of a three-factor equation (calories-in/calories-out/metabolic-profile), not just the two-factor calories-in/calories-out." (7) Here Ayurveda comes into its own with a profound understanding of individual metabolic profile based on the prakruti-vikruti paradigm.
At the same time, Ayurvedic practitioners can benefit from an enhanced understanding of the complexities of meda dhatu and meda dhatu agni as revealed in cutting edge biomedical research. Three important points need to be appreciated. The first thing we need to grasp is that there are two different types of fat tissue, Visceral Adipose Tissue (VAT) and Subcutaneous Adipose Tissue (SCAT). Second, adipose tissue (meda dhatu) functions as an endocrine organ secreting an array of hormones important to heath and disease. Third, VAT and SCAT have different endocrine profiles and so impact the body differently.
As an important article in Nutrition and Metabolism notes, "VAT depots, located in the body cavity beneath the abdominal muscles, are composed of the greater and lesser omentum (peritoneum that is attached to the stomach and links it with other abdominal organs) and the mesenteric fat. A lesser amount of VAT is located retroperitoneally. In general, VAT accounts for up to 20 percent of total fat in men and 5-8 percent in women. The abdominal SCAT is located immediately beneath the skin and on top of the abdominal musculature. The predominance of lower body fat is SCAT, most of which is stored in the femoral and gluteal regions."(8). It is VAT that is chiefly associated with Metabolic Syndrome (also known as Syndrome X or insulin resistance). Pear-shaped individuals have more of the relatively benign SCAT and apple-shaped individuals have more VAT. This is the reason why obesity in men, who develop a VAT-style potbelly as they age, carries a higher risk factor than in women, who have a greater proportion of hip and thigh SCAT.
The latest research highlights the close connection between the meda and majja dhatus, in that the hormonal functions of adipose tissue are carried out both by adipocytes (meda dhatu cells) and by majja-related cells such as macrophages, a type of white blood cell produced in bone marrow and residing in fatty tissue. The proportion of macrophages in VAT increases with obesity (9). These macrophages express more inflammatory chemokines and more resistin and visfatin than do adipocytes, pointing to an understanding of obesity as an inflammatory disorder (9). Critical hormones produced in meda dhatu include leptin, tumor necrosis factor alpha, resistin, adiponectin, interleukin-6, free fatty acids, visfatin, omentin, perilipin, angiotensin and oestradiol. Leptin plays a key role in regulating appetite and metabolism, signalling to the body that it has taken in sufficient food. Leptin production increases in proportion to the amount of adipose tissue in the body, thus helping regulate body mass by decreasing appetite and increasing metabolism and fat burning. Obese individuals have high levels of leptin but appear to be leptin resistant, perhaps because the enlarged and fat-bloated adipocytes of obesity have an impaired ability to respond to leptin (8). Although obese individuals have high circulating levels of leptin, the hypothalamus fails to respond by reducing appetite signalling (10). This is a modern biochemical explanation of the issue of increased agni and excess appetite in obesity, which Madhav Nidhan grapples with.
Adiponectin is anti-inflammatory, protects blood vessel walls and enhances insulin sensitivity. Although adiponectin is produced in adipose tissue, its levels decline in direct proportion to the amount of VAT in the body. This may again be due to impaired functioning of enlarged adipocytes. (7). Lowered levels of adiponectin are associated with hypertension, metabolic syndrome, adult onset diabetes and cardiovascular disease(8). Essentially, obesity impairs the critical functions of meda dhatu agni, setting off a positive feedback loop in which increased amounts of meda dhatu lead to greater impairment of meda dhatu agni which leads to further increases in meda dhatu.
Secreted by adipocytes and in even greater quantity by the macrophages present in the VAT of obese individuals, Resistin appears to be the biochemical messenger inducing insulin resistance and giving rise to Metabolic Syndrome and Type 2 diabetes. "Resistin is a signalling molecule that is induced during adipogenesis and secreted by adipocytes. Resistin expression in vivo is specific to white adipose tissue, and resistin is found in the serum of normal mice. Resistin levels are increased in diet-induced obesity as well as in genetic models of obesity and insulin resistance. Resistin is therefore a candidate adipocyte derived factor that contributes to insulin resistance in vivo." (11).
In assessing an individual who complains of excess weight, it is important to determine both what is that person's optimum weight as well as what is the cause of their current excess weight. A useful BMI website is http://www.halls.md/body-mass-index/bmi.htm which assesses not only body mass index but also the percentile on which the person fall in terms of gender, age, height and weight. A healthy vata should fall at or below the 40th percentile; a healthy pitta should be around or below the 50th percentile and a healthy kapha might be around the 60th percentile.
The proportion of VAT and abdominal fat versus hip and thigh SCAT is also significant and is determined by measuring waist and hips. The optimal waist hip ratio (WHR) is 0.7 for women and 0.9 for men. After taking your client's measurements, WHR can be calculated at http://www.bmi-calculator.net/waist-to-hip-ratio-calculator/ . For a female, 0.8 or below is low risk, 0.8-0.85 is medium risk and above this is high risk. For a male the corresponding figures are 0.95 or below, 0.95-1.0 and above 1.0. Understanding these proportions helps practitioners give appropriate advice to the 'fit fat' and metabolically obese person. For example, a 6' pitta-kapha male weighing 184 lb has a BMI of 25 at age 50. He presents with high blood pressure and elevated blood sugar. Although of normal weight, he has a WHR of 0.98 as a long term result of a previous history of alcohol abuse. This patient is an example of a metabolically obese normal weight individual (MONW) whose presenting symptoms of metabolic syndrome (kapha syndrome) are a result of excess VAT accumulation. Although he is of normal weight, he requires a weight loss programme to address his metabolic obesity.
Other causes of obesity that should be considered include hypothyroidism, depression, eating disorders and a history of low calorie diets. To assess thyroid function, the client should be asked to chart their basal temperature immediately upon waking each morning. One kapha male, a salesman, presented me with impressive bar charts showing that his basal temperature was usually 96.0 or below, far lower than 97.8, which represents the low end of the normal range. To determine the presence of eating disorders, ask direct questions regarding everything the patient eats after dinner. "Do you eat a large bag of M&M's after dinner?" It is quite surprising how often the answer is a sheepish 'Yes" or "Well, not the whole bag."
Overweight or obesity related to stress and depression is often due to elevated cortisol levels. It is crucial for these patients to eat a protein snack such as sunflower seeds, goat cheese or humus with baby carrots at four in the afternoon. On an herbal level, Tulsi is excellent for elevated cortisol levels (12). Drinking Tulsi-Brahmi tea three times daily will support normalization of weight in depressed, stressed or traumatized individuals. Daily use of a nasya oil containing nervine herbs such as Brahmi, Calamus Root and Skullcap, will also help normalize weight through balancing mood and harmonizing neurotransmitters (13).
As metabolism slows and weight increases, the meal pyramid must be re-arranged. Weight-conscious would-be dieters often skip breakfast and eat a salad for lunch. By evening they are ravenous and have a heavy meal followed by a succession of high calorie snacks. Instead, overweight individuals should start with a protein breakfast such as dal or an egg-white omelet, take their main meal at lunch, and have a protein snack mid-afternoon and a light dinner such as soup or salad.
When selecting herbs for weight loss, it is important to consider agni type. Overeaters are often kapha types with mandagni, who are eating for emotional reasons rather than for hunger. On the other hand, a pitta type with tikshnagni may consume excess food due to being over-hungry. And a vishamagni type vata under-eater may eventually become MONW due to overdoing salty, oily bagged snacks and developing excess VAT on an otherwise slim frame. The mandagni type will benefit from Chitrak, Trikatu and Triphala Guggulu to normalize appetite and metabolism and to kindle meda dhatu agni. Triphala Guggulu will also help scrape away VAT. The tikshnagni type can take Shatavari Kalpa in the morning to calm the digestive fire and normalize appetite (Roast an ounce of Shatavari with one or two tablespoons ghee in a cast iron pan until light brown and add two tablespoons of sucanat, rapadura or turbinado sugar, two pinches saffron and a pinch of cardamom.) At bedtime they can take Amalaki, which will also help balance tikshnagni. If there is tikshnagni, Chitrak may cause a net weight gain by further increasing agni. The MONW vata can take Dashamoola to normalize vishamagni and Yogaraj Guggulu to scrape excess VAT and eliminate vata toxins. Following the diet guidelines for prakruti type is also essential for balancing and maintaining agni.
For metabolic syndrome, Shardunika enhances insulin secretion and Turmeric (14) and Neem (15) improve insulin sensitivity. A typical patient comment once insulin sensitivity improves is, "I haven't lost much weight, but now the weight is in the right places. My clothes fit better and I look better." A typical kapha syndrome patient will have metabolic syndrome or adult-onset diabetes as well as hypothyroidism. For hypothyroidism, Punarnava, Chitrak, and Shilajit will help kindle the agni of the thyroid gland and improve thyroid function.
By combining herbal support of this kind with a balanced meal pyramid, prakruti-specific diet and regular exercise, weight can be lost in a gradual and sustainable manner and the ratio of VAT to SCAT improved, leading to metabolic balance. Herbal support in kindling meda dhatu agni and improving insulin sensitivity can take the obese individual out of a negative spiral, providing an added therapeutic dimension with results greater than that of diet and exercise alone.
1. Srikantha Murthy tr. Madhav Nidhanam Ch 34 Chaukhambha Orientalia, Varansi, 2007
2. Kenneth G. MacDonald Jr, MD, Overview of the Epidemiology of Obesity and the Early History of Procedures to Remedy Morbid Obesity, Arch Surg. 2003;138:357-360.
3. Hellmich N. Obesity in America is worse than ever. USA Today. October 9, 2002.
6. Council on Scientific Affairs. "Obesity as a Major Public Health Problem" (Resolution 423, A-98). Chicago, IL: American Medical Association, CSA Report A-99, Feb. 1, 1999
7. Steven Jonas, M.D., M.P.H., M.S. American Medical Athletics Association Journal, Summer, 2004
8. Eric S Freedland, Role of a critical visceral adipose tissue threshold (CVATT) in metabolic syndrome: implications for controlling dietary carbohydrates: a review Nutrition & Metabolism 2004, 1:12
9. C. A. Curat, V. Wegner et al, Macrophages in human visceral adipose tissue: increased accumulation in obesity and a source of resistin and visfatin Diabetologia Volume 49, Number 4, 744-747, DOI: 10.1007/s00125-006-0173-z
10. Heike Münzberg1 & Martin G Myers Molecular and anatomical determinants of central leptin resistance
Nature Neuroscience 8, 566 - 570 (2005) Published online: 26 April 2005 | doi:10.1038/nn1454
12. James A. (Jim) Duke. The Garden Pharmacy: Basil as the Holy Hindu HighnessAlternative and Complementary Therapies. February 2008, 14(1): 5-8. doi:10.1089/act.2008.14101.
13. S Talegaonkar, PR Mishra Intranasal delivery: An approach to bypass the blood brain barrier
EDUCATION FORUM 2004 Volume : 36 Issue : 3 Page : 140-147
15. Anita Kochhar, Neha Sharma and Rajbir Sachdeva Effect of Supplementation of Tulsi (Ocimum sanctum) and
Neem (Azadirachta indica) Leaf Powder on Diabetic Symptoms,Anthropometric Parameters and Blood Pressure of Non Insulin Dependent Male Diabetics Ethno-Med, 3(1): 5-9 (2009)