AcharyaCharakahas mentioned the Nidanaof Sthaulyaanalytically in most of them is exogenous types of causes. Endogenous types of causes have been mentioned by AcharyaSushrutaand Vagbhatta. AcharyaVagbhattaalso mentioned Amaas causative factor. Only AcharyaCharakahas defined Beejadoshaas one of the cause of Sthaulya. In context with Sthaulya, exogenous causes are Medastimulating diet and regimens where as Dosha, Dhatu, Mala and Srotasetc. come under endogenous causes.

All the Nidana(causative factors) mentioned in Ayurvedic classics can be classified into 4 groups – Aharatmakanidana, ViharatmakaNidana, ManasNidanaand Anya Nidana.

Anupa Rasa Sevan, Atisampurana(over eating), Guru AharaSevana (excessive consumption of food), MamsaSevana(Excessive use of meat), Ikshu Vicar Sevana(sugarcanes preparations), PayasVikaraSevana(milk and its preparations), ShleshmalaAharaSevana (Kapha increasing food)

Avayama(Lack of physical exercise), SukhaShayya(Luxurious sitting), Bhojanottaridra(sleep after meal), Alpavyavaya(Reduced sex life), Gandhamalyanusevana(use of perfumes and garlands).

Achintana, Harshanitya, Manasonivritti have been considered as the ManasikaNidanas of Sthaulya in Ayurveda.

Acharya Charaka has specifically mentioned Beejadosha as the Nidana for Sthaulya and Chakrapani comments over it as “Beejaswabhavadi AtiSthula Mata Pitru Janyatvat”

Three main causes have been described in modern literature viz.

The physical effects of obesity are even more disturbing. It is producing heart diseases which have been recognized as the leading killer disease of 21^st century. Obesity also lays down of the foundation variety of other disorders ranging from diabetes to impotency. All these disorders are indication of failing systems. It is statistically proved that longevity is greatly reduced in an obese living in the present day.

At an individual level, a combination of excessive caloric intake and a lack of physical activity are thought to explain most cases of obesity[9]. In contrast, increasing rates of obesity at a societal level are felt to be due to an easily accessible and palatable diet, increased reliance on cars, and mechanized manufacturing. A limited number of cases are due primarily to genetics, medical reasons, or psychiatric illness.

Apart from several rare genetic syndromes (listed above) other Medical illnesses that increase obesity risk include: hypothyroidism, Cushing's syndrome, growth hormone deficiency, and the eating disorders: binge eating disorder and night eating syndrome. Certain medications may cause weight gain or changes in body composition; these include insulin, sulfonylureas, thiazolidinediones, atypical antipsychotics, antidepressants, steroids, certain anticonvulsants (phenytoin and valproate), pizotifen and some forms of hormonal contraception.¹⁰

For the purpose of Diagnosis, Prognosis and easy management disease should be classified as per severity as well as chronicity. Hence, classification of Sthaulyais essential. But there is no such clear classification was found in ancient classics. AstangaSangraha, AstangaHridaya and SharangadharaSamhitahave thrown little light regarding classification of Sthaulya. As mentioned there are three types of Sthaulyai.e. Adhika, Madhyaand Hinahave been mentioned for better management while narrating the indication LanghanaUpakrama.

According to AcharyaCharaka[11], Sushrutaand Sharangadharaalso accepted the view of Sushruta, considering all these references Sthaulyamay be classified as:-

The primary goal of treatment is to improve obesity-related comorbid conditions and reduce the risk of developing future co morbidities. Information obtained from the history, physical examination, and diagnostic tests is used to determine risk and develop a treatment plan. The decision of how aggressively to treat the patient, and which modalities to use, is determined by the patient's risk status, expectations, and available resources. Therapy for obesity always begins with lifestyle management and may include pharmacotherapy or surgery, depending on BMI risk category. Setting an initial weight-loss goal of 10% over 6 months is a realistic target.

In Ayurveda, various plant based drugs are advocated for the prevention and management of obesity, diabetes and dyslipidemia. In Ayurveda metabolic syndrome and its association with diabetes (Prameha) can be correlated with obesity (Medo-Roga). Various pharmacologic and non-pharmacologic methods has been prescribed in Ayurveda for treatment of Obesity In obesity (Medo-Roga), those drugs which have Rasayana, Balya and Jivaniya action, as well as Pramehaghna properties like Silajatu, Amalaki, Haridra, Guduchi, Pippalietc. are useful. Sushruta has indicated Silajatu (NaimittikaRasayana) together with decoction of SalasaradiganaDravyas for the treatment of Madhumeha, these all Drugs having Rasayana and Jivaniya properties along with Pramehaghna properties such as Amalaki, Haridra, Silajatu, Guduchi etc. are given as an adjuvant to known (conventional) hypoglycemic agents effective in Obesity (Medo-Roga). Such kinds of drugs help to, reduce insulin requirement, prevent or delay long-term complications, generate sense of well being and maintain healthy life.

Obesity care involves attention to three essential elements of lifestyle: dietary habits, physical activity, and behaviour modification. Because obesity is fundamentally a disease of energy imbalance, all patients must learn how and when energy is consumed (diet), how and when energy is expended (physical activity), and how to incorporate this information into their daily life (behaviour therapy). Lifestyle management has been shown to result in a modest (typically 3–5 kg) weight loss compared to no treatment or usual care.

The primary focus of diet therapy is to reduce overall calorie consumption. The NHLBI guidelines recommend initiating treatment with a calorie deficit of 500–1000 kcal/d compared to the patient's habitual diet. This reduction is consistent with a goal of losing approximately 1–2 lb per week. This calorie deficit can be accomplished by suggesting substitutions or alternatives to the diet. Examples include choosing smaller portion sizes, eating more fruits and vegetables, consuming more whole-grain cereals, selecting leaner cuts of meat and skimmed dairy products, reducing fried foods and other added fats and oils, and drinking water instead of caloric beverages. It is important that the dietary counselling remains patient-centric and that the goals are practical, realistic, and achievable.

Although exercise alone is only moderately effective for weight loss, the combination of dietary modification and exercise is the most effective behavioural approach for the treatment of obesity. The most important role of exercise appears to be in the maintenance of the weight loss. Currently, the minimum public health recommendation for physical activity is 30 min of moderate intensity physical activity on most, and preferably all, days of the week. Focusing on simple ways to add physical activity into the normal daily routine through leisure activities, travel, and domestic work should be suggested. Examples include walking, using the stairs, doing home and yard work, and engaging in sport activities. Asking the patient to wear a pedometer to monitor total accumulation of steps as part of the activities of daily living is a useful strategy. Step counts are highly correlated with activity level. Studies have demonstrated that lifestyle activities are as effective as structured exercise programs for improving cardio-respiratory fitness and weight loss.

Cognitive behavioural therapy is used to help change and reinforce new dietary and physical activity behaviours. Strategies include self-monitoring techniques (e.g., journaling, weighing, and measuring food and activity); stress management; stimulus control (e.g., using smaller plates, not eating in front of the television or in the car); social support; problem solving; and cognitive restructuring to help patients develop more positive and realistic thoughts about themselves. When recommending any behavioural lifestyle change, have the patient identify what, when, where, and how the behavioural change will be performed. The patient should keep a record of the anticipated behavioural change so that progress can be reviewed at the next office visit. Because these techniques are time-consuming to implement, they are often provided by ancillary office staff such as a nurse clinician or registered dietician.

The fat which is not mobile and is stored in the form of fat at various places [fat depots/muscles] in the body is termed as “BaddhaMeda”.

The fat, which is mobile and circulates in the body along with blood in the form of lipids [Cholesterol, Triglycerides, LDL, HDL and VLDL etc.] is termed as “AbaddhaMeda”.

Excessive AbaddhaMedais stored as fat [BaddhaMeda] in the body in the form of serum triglycerides in adipose tissues, resulting in accumulation of more adipose tissues and increased adiposity in the body which is termed as Obesity.

Sthaulya is a Dushya dominant disorder, in pathogenesis of Sthaulya, all the three Doshas are vitiated especially KledakaKapha, Pachak Pitta, SamanVayu&VyanVayu which are responsible factors for proper digestion and metabolism of food at the level of alimentary tract. [15] Due to excess hunger and thirst, Annarasa is formed and specificity of diet i.e. Guru, Madhura, Snigdha; SheetGuna dominance DhatuPoshakanshis formed in more quantity. Initially the Rasagat, Raktagatand MamsagatSnehaalso increase the production of Medadhatu. But due to Medodhatwagnimandyathis condition worsens and nourishment of further Dhatus doesn’t happen properly. Due to binge eating, Rasa RaktMamsagatSnehastarts to increase. Patient shows the symptoms of Rasavriddhi and Kaphavriddhi.e.g. Angagaurav, Alasya, Tandraand Nidradhikya. Medadhatu gets increase with physical signs like ChalSphik-Udar-Stana, KshudraShwas, Swedadhikyaetc and finally lands into Sthaulya. Whatever diet is taken due to its specific affinity to MedaDhatu, it directly converts to MedoDhatu. This has been clearly mentioned by AcharyaSushruta and the commentator Dalhana clearly explains that bypassing two Dhatus i.e. Rakta and Mamsa only MedaDhatu is excessively formed in the patients of Sthaulya. Acharya Charak has divided Nidanas in 4 categories i.e. Atisampurana, Avyayam, Harsanityatva and Beejaswabhava. If patient is having less number of etiological factors, Sthaulya will be less complicated and easily curable. However if these factors gets association with BeejaDosha, patient quickly reaches to Atisthaulya condition and it becomes incurable or Yapya. Hence while assessing Sadhyasadhyata, Severity of etiological factors should be considered. So whenever Rasa – Rakta – MamsagataSneha starts to increase due to excessive eating and less calorie consumption, a pressure on Dhatwagni starts to build up. Patient shows the symptoms of Rasavriddhi (RasagataSnehansa) and KaphaVriddhi e.g. Angagaurava, Alasya, Tandra and Nidradhikya etc. Later on actual MedoDhatu gets clinical increase and this increase of Meda reflects with various physical signs like ChalaSphika – Udara – Stana, Ksudra -Swasa, Swedadhikya etc. and in later stages difficulty in performing all his daily activities. Further improper nutrition to Asthi, Majja and ShukraDhatu may also take place.