|Year : 2014 | Volume
| Issue : 2 | Page : 89-94
Obesity and osteoarthritis comorbidity: Insights from Ayurveda
Ashwinikumar A. Raut1, Manohar S. Gundeti2
1 Clinical Research and Integrative Medicine, MRC KHS, Vile Parle West, Mumbai, Maharashtra, India
2 Department of Ayush, RRA Podar Ayurveda Cancer Research Institute (CCRAS), MoH and FW, Goi, Worli, Mumbai, Maharashtra, India
|Date of Submission||13-Feb-2014|
|Date of Decision||21-Mar-2014|
|Date of Acceptance||01-Apr-2014|
|Date of Web Publication||12-Jun-2014|
Ashwinikumar A. Raut
Clinical Research and Integrative Medicine, MRC KHS, K Desai Road, Vile Parle West, Mumbai 400 054, Maharashtra
Source of Support: None, Conflict of Interest: None
Obesity and osteoarthritis are globally reaching epidemic proportions. Their concomitant association is well-known. The cumulative impact of these conditions on morbidity and the quality-of-life is sizeable, particularly for the aged. Obesity leading to osteoarthritis of the weight-bearing joints is well-appreciated. Inversely, however it is less emphasised that osteoarthritis of big joints of the lower limbs contributes to obesity because of the resultant physical inactivity. The increased adiposity is known to secrete proinflammatory cytokines that adds to the biomechanical cause of osteoarthritis. Besides mechanical and inflammatory mechanisms, genetic factors also play a causative role in both obesity and osteoarthritis as separate and concomitant disorders. The genetic and epigenetic mechanisms are gradually being unravelled for the comorbidity of obesity and osteoarthritis. Thus, the molecular pathophysiology of the concomitant existence of obesity and osteoarthritis is highly intriguing. Identifying the appropriate choice and sequence of therapeutic targets for reversal of this complex pathogenesis is a challenging task. Ayurvedic understanding of this comorbidity and experiential therapeutic base can offer a strategy for the prevention and management of the disorders. "Sthaulya" and "Sandhigatavata" are the respective clinical syndromes, described in Ayurveda for obesity and osteoarthritis. The imbalance in the respective "Dhatvagni" (metabolic paths) of "Meda-Dhatu" (adipose tissue) and "Asthi-Dhatu" (bone tissue) is the putative central pathogenetic mechanism involved for the comorbidity. The present article analyses some of the insights and experience from Ayurveda so as to provoke a meaningful debate on the opportunities for integrative care for obesity related osteoarthritis through reverse pharmacology path.
Keywords: Ayurvedic therapy, integrative Ayurveda, obesity, osteoarthritis, reverse pharmacology, traditional medicine, translational research
|How to cite this article:|
Raut AA, Gundeti MS. Obesity and osteoarthritis comorbidity: Insights from Ayurveda. J Obes Metab Res 2014;1:89-94
| Introduction|| |
Obesity and osteoarthritis, both chronic clinical conditions, are reaching the magnitude of epidemic proportion. This is more so in the developed countries. In developing countries, the prevalence is more in urban areas. There is a direct link to the changing lifestyles. In the US, 35.7% of the adult population (age > 20 years) and 16.9% of children and adolescent (age 2-19 years) are obese (body mass index [BMI] >30).  In India too, there is a growing trend. In Delhi urban area, 24.2% adolescent school children (14-18 years) are obese/overweight.  In a recent Mumbai-based school-study of children from the higher socioeconomic stratum 26.7% children were obese/overweight.  A study from Chennai indicates an increasing trend of obesity in the rural population as well.  In fact, with a different phenotype of obesity in the South Asians, lower cut-offs for BMI and waist circumference are proposed.  In the US, 27 million people are estimated to be suffering from osteoarthritis.  In the Indian population (age > 15 years), the prevalence of osteoarthritis in rural and urban area ranges from 4% to 6% , amounting to 65 million adult people. 
Osteoarthritis is responsible for long years with disability.  As obesity and osteoarthritis both these conditions occur more in the elderly, there is a major impact on the quality of life and individual productivity.  The obese are 4 times more likely to develop osteoarthritis and is a condition difficult to manage. Moreover, severity of osteoarthritis increases with an increase in BMI. 
Genetic predisposition and errant lifestyle are significantly associated with both obesity and osteoarthritis. , However, in an adult rural population an association of the family history of osteoarthritis and higher BMI was not observed. 
Chronic low-grade inflammation is emerging as the substratum of obesity and osteoarthritis comorbidity.  The biomechanical impact of obesity on the weight-bearing joints activates low grade inflammation and perpetuates cartilage degradation.  The adipose tissue through its diverse adipokines plays a role in the inflammatory process and eventual joint damage. A reduction in body weight by conservative management or bariatric surgery is known to ameliorate the severity of osteoarthritis. 
With the unravelling of common intricate molecular mechanisms of obesity and osteoarthritis novel therapeutic targets are identified for new drug discovery and development.  The mainstream medical management currently relies on diet, exercise and analgesics/anti-inflammatory drugs for the obesity-osteoarthritis comorbid condition [Table 1]. Pharmacotherapy of obesity has limitations due to safety issues,  whereas so far no disease-modifying or structure-modifying intervention has been proved effective in osteoarthritis.  Having target-specific, non-invasive, safe, effective, economical, and acceptable therapeutic modality appears to be still a distant dream for osteoarthritis-obesity comorbidity.
In this article, we shall explore some of the relevant fundamental concepts and practices of Ayurveda, pathophysiology of Sthaulya (obesity), pathophysiology of Sandhigatavata (osteoarthritis) and Vyadhi - sankara ghataka (factors of comorbid pathology). Ayurvedic therapeutic approaches and modalities may provide us insights into the potential leads, which can be pursued through reverse pharmacology approach. 
| Relevant Concepts of Ayurveda|| |
|Table 1: Conventional management approach for obesity and osteoarthritis |
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0Ayurveda is a holistic science mainly dealing with knowledge of life and practised as a healthcare system. The fundamental concepts are derived primarily from six Indian philosophies viz. Sankhya, Vaisheshika, Nyaya, Yoga, Poorvamimansa and Uttarmimansa. Ayurveda is based on the axiom of the microcosm-macrocosm-continuum. Panchamahabhuta doctrine proposes that the universe is made up of Prithvi-earth, Jala-water, Teja-fire, Vayu-air, and Akash-space. The addition of "Chetan-Tatva" to these five basic elements of panchamahabhuta brings life. Chetan-Tatva is Atman-soul which works through Manas-mind. Manas-mind has three qualities as Satva, Rajas, and Tamas. Ayurvedic physiology broadly is explained in terms of Dosha-biological forces, Dhatu-basic tissues and Mala-waste products. The three Dosha are manifested differently such as, Vata-manifested by movements and functions, Pitta-manifested by bodily heat and metabolism and Kapha-manifested by bodily water and cohesiveness. Homeostasis of these three forces maintains health and its imbalance leads to diseases. The physical construct of the human body is grossly made up of SaptaDhatu-seven basic tissues, viz. Rasa-plasma, Rakta-blood, Mansa-muscle, Meda-fat, Asthi-bones, Majja-marrow, and Shukra-semen/ovum. During continuous process of metabolism, the Mala-biological wastes produced are supposed to be excreted out of the system. Human biological system for digestion, metabolism and assimilation is referred as "Agni," whereas the process of bio-transformation and bio-transportation takes place through bodily channels referred as "Srotas". Agni is broadly categorised into three viz. Jatharagni, Bhutagni, and Dhatvagni. The Jatharagni is primarily responsible for digestion in the gastrointestinal tract; Bhutagni makes these digested constituents bio-compatible through metabolism and Dhatvagni essentially contributes in the assimilation of these digested and metabolised substances into pertinent tissue components. Dysregulation of "Agni" and obstruction of "Srotas" are considered as the major pathogenetic factors in Ayurvedic understanding of pathophysiology of any disease.
| Pathophysiology of Sthaulya (Obesity)|| |
0Sthaulya or Atisthaulya (morbid obesity) is the outcome of Medoroga (disease of adipose tissue and lipid disorder) in Ayurveda. Sthaulya is caused by dietetic, lifestyle, psychological and hereditary factors as described in classics attributed to the aggravation of Kapha. This aggravated Kapha-Dosha downregulates Jatharagni and eventually subdues Meda-Dhatvagni (fat metabolism and lipid assimilative process) and produces Ama (unassimilated toxic residues) which vitiates and further increases Meda-Dhatu (adipose tissue and lipids). This increased and vitiated Meda-Dhatu causes obstruction in different Srotas (bodily channels) leading to aggravation and dysregulation of Vata-Dosha function. This deregulated Vata-Dosha on one hand resets the satiety and feeding centre in favour of further increase in food intake and on the other hand vitiates all the other Dhatus. Vitiation of all Dhatus cause different metabolic disorders and complications of obesity. Bahu-Abaddha-Meda (excessive and dysfunctional adipose tissue) and Udareshuvruddhi (central abdominal obesity) are considered as characteristics of excessive fat mass responsible for Sthaulya.
| Pathophysiology of Sandhigatavata (Osteoarthritis)|| |
Sandhigatavata denotes aggravation of Vata-Dosha affecting articular structures leading to joint failure. Increase of Vata-Dosha is known with the aging process besides diet and lifestyle complementary to Vata-Dosha properties. However, in the human system aggravation of Vata-Dosha in general may occur either due to Dhatu-Kshaya (degenerative tissue changes) or due to Margavarodha (obstructive pathogenesis). In the context of Sandhigatavata; Asthi-Dhatu-Kshaya (loss of bone and cartilage structure) is impeded due to hypo-functioning and derangement of Asthi-Dhatvagni (bone and cartilage related assimilative process). This adversely affected homeostasis at the level of Asthi-Dhatvagni coupled with independently aggravated Vata-Dosha; increases catabolic process leading to degenerative changes in the joint structure (Sandhi-Hanana). Margavarodha (obstructive pathogenesis) often is caused due to Ama (unassimilated toxic residue) and association of which often leads to immunoinflammatory pathology. When clinically evident this condition is called as Sama-Sandhigatavata. Otherwise, when it occurs exclusively due to Vata-Dosha without the involvement of Ama the condition is supposed to be Nanatmaja-Sandhigatavata.
| Ayurvedic Perspective of Comorbidity|| |
Vyadhi-Sankar is the term used for comorbidity in Ayurveda.  The diagrammatic representation of Ayurvedic perspective of obesity and osteoarthritis comorbidity is depicted in [Figure 1]. Sapta-Dhatu (seven basic tissues) are formed and developed by three hypotheses such as, (1) Khale-Kapota-Nyaya, (selective development of each Dhatu through respective nutrients), (2) Kedari-Kulya-Nyaya, (sequential development of one Dhatu after another), (3) Ksheera-Dadhi-Nyaya, (transformational development of one dhatu into another). It is interesting to note that "Meda-Dhatu" and "Asthi-Dhatu" of concern in obesity and osteoarthritis are next to each other in the sequence of Sapta-Dhatu. We now know that adipocytes share common mesenchymal stem cell precursors with chondrocytes and osteoblasts, suggesting a link between lipid metabolism and these connective tissues.  Pathophysiology of Sthaulya (obesity) and Sandhigatavata (osteoarthritis) is independently described earlier (vide-supra). Sandhigatavata is considered as a Vatavyadhi (diseases with predominant degenerative pathobiology), whereas Shtaulya has an impact of Ayushorhasa (reduced life expectancy) and javaparodha (early aging).  It is now scientifically demonstrated that obesity and osteoarthritis both these diseases are associated with early ageing changes and cellular senescent degeneration. , In the context of comorbidity of Sandhigatavata and Sthaulya, Dhatwagnii-Vaishamya (dysregulation of metabolic paths), Ama-Nirmiti (production of unassimilated toxic residue), Srotorodha (obstruction in body channels), Mala-Sanchiti (accumulation of bio-waste), Vata-Prakopa (aggravation of Vata-Dosha), Dhatu-Kshaya (degeneration of Dhatu), and Dhatu-Shaithilya (loss of cohesiveness and quality of Dhatu) are the important Vyadhi-sankar ghatak (factors of comorbid pathology) for the therapeutic targets.
|Figure 1. Rasa, Rakta, Mansa, Meda, Asthi, Majja, Shukra: Seven basic tissues called Sapta Dhatu, Meda-Dhatvagni: Metabolic paths for adipose tissue. Asthi-Dhatwagni: Metabolic paths for bone tissues. Agni-Vaishamya: Dysregulation of metabolic paths. Ama-Nirmiti: Production of unassimilated toxic residue. Srotorodha: Obstruction in body channels. Mala-Sanchiti: Accumulation of bio-waste. Vata-Prakopa: Aggravation of Vata-Dosha. Vata-Vimarga: Reverse movement of Vata-Dosha. Dhatu-Kshaya: Degeneration of Dhatu. Dhatu-Shaithilya: Loss of cohesiveness and quality of Dhatu. Asthi-Sandhi-Hanana: degeneration of joint structures. Akarmanyata: Restriction in movement and locomotion. Bahu-Abaddha-Meda: Excessive and dysfunctional adiposity|
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| Insights in Ayurvedic Management|| |
On the foundation of macrocosm-microcosm-continuum; Ayurvedic therapeutics is broadly classified as Daivya-vyapashraya (Divine therapies; inclusive of wearing precious stones, reciting prayers, chanting mantras, performing homa-havan, etc.), Yuktivyapashraya (Rational therapies; based on logistics of therapeutic principles), and Satvavajaya (control on mind; yoga and meditation). Management principle of therapeutics is the reversal of pathogenesis which includes Nidana Parivarjana (avoiding causative and precipitating factors), Sanshamana Chikitsa (restoration of physiological homeostasis), Sanshodhana Chikitsa (detoxification procedures for correcting human system), and Rasayana Chikitsa (rejuvenative and reparative medicine). However, current mainstream Ayurveda practice primarily adheres to the tenets of Yuktivyapashraya Chikitsa. In the context of obesity-osteoarthritis comorbidity management a broad classical management approach is depicted in [Table 2]. This comprises dietary modulation, and nutraceutical remedies; self-efficacy through lifestyle correction and physical exercise; and medical management through physical therapy, pharmacotherapy, panchakarma procedures, and surgical interventions.
Non-pharmacological management of obesity in Ayurveda as well as in modern medicine through dietary modification and lifestyle measures has similar therapeutic intent of weight reduction.  Weight reduction benefits in osteoarthritis with obesity are well-documented and accepted.  However, dietary modification in osteoarthritis is unique to Ayurveda, which is intended to pacify "Aggravated Vata-Dosha" and prevent "Dhatu-Kshaya". This includes avoidance of food substances with bitter, pungent, astringent taste, stale and stored food items, dry food substance, etc. Here is a scope for research to demonstrate the cause-effect relationship between Ayurvedic dietary modulation and relief in osteoarthritis without the confounding of weight reduction. Similarly, specific dietary substances such as honey with water, Shashtishali (kind of rice), Java (barley), Nachani (ragi), Kulattha (horse gram), vari (kind of millet) takrarishta, (fermented butter milk), vegetables like Patola (kind of gourd) are recommended for obesity based on Ayurvedic rationale. Large-scale observational studies would help demonstrate the relevance of these specific food items.
Panchakarma and complementary therapies are recommended in obesity and osteoarthritis. For obesity Abhyanga (medicated oil massage), Udvartana (upward powder massage), Snana (medicated baths), Parisheka (medicated showers), Vamana (induced vomiting), Virechana (purgation), LekhanaBasti (Detoxifying per rectal procedures), are used. Whereas for osteoarthritis Lepa (topical application of medicines), Swedana (sudation), Jalaukavacharana (Leech application), Agnikarma (transcutaneous heat therapy), Viddhakarma (acupuncture therapy), Basti (various medicated enema), Snehana (application of oil) are recommended. Local applications of medicated oils; classical as well as proprietary is abundantly available in the market and is widely used for osteoarthritis.
Several studies are conducted on Panchakarma and allied procedures for the indication of obesity and osteoarthritis at teaching and research institutions of Ayurveda across the country. ,,,. However, more scientific rigor is desired through multidisciplinary integrative research programmes to get better insight into these traditional practices.
| Integrative Therapeutics through Reverse Pharmacology|| |
Pharmacotherapy in Ayurveda is primarily resourced from plants besides from animals, minerals, and metals after due purification and pharmaceutical processes. In classical literature about 78,000 Ayurvedic medicinal products are documented.  Many such classical Ayurvedic formulations are indicated for obesity  as well as for arthritis.  With about 8000 licensed manufactures in the country,  several proprietary Ayurvedic products are available in the market and innumerable home remedies through kitchen Ayurveda are consumed in millions of household. This is a huge unaccounted use of Ayurvedic medicines.
To comprehend the actual usage for specific indications such as obesity or osteoarthritis, range of the dose being consumed, concomitant ancillary Ayurvedic measures followed, general safety index, and many other details of drug utilisation may be evaluated and documented on the guidelines of Ayurvedic Pharmacoepidemiology. , Further to this Ayurvedic medicinal usage database, it is possible to short-list the potential hints through observational therapeutics, detailed records of a single case studies and series of case reports. , These hints can be further translated into hits, leads and candidates for drug discovery through a trans-discipline of reverse pharmacology. Comprehending Ayurvedic rationale, hypothesising the mechanism of action, pharmacognostic, phytochemical, and pharmaceutical standardisation are pre-requisites of reverse pharmacology studies. 
Based on available classical Ayurveda references, continued traditional experiences, conventional research reports on Ayurvedic pharmacotherapy for obesity/osteoarthritis, considering pathogenetic factors of comorbidity and applying Ayurvedic rationale we have short-listed formulations and plants potentially useful in comorbidity of obesity with osteoarthritis [Table 3].
|Table 3: Selected Ayurvedic pharmacotherapy for obesity and osteoarthritis co-morbidity* |
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| Conclusion|| |
Obesity and osteoarthritis comorbidity is increasing globally due to changing lifestyle with rapid urbanisation. Adipose tissue and articular cartilage are the main organs involved with chronic low-grade inflammation and progressive cellular senescence. This comorbidity is often further complicated with associated morbidity of insulin resistance, dyslipidaemia, atherogenesis, hyperuricemia, carcinogenesis, and others.
Lifestyle management of this comorbidity share same intent in Ayurveda and in modern medicine. However unique dietary modulation in the management of obesity/osteoarthritis based on Ayurvedic principles need attention to understand the cause-effect relationship in therapeutic benefits. Conventionally for irreversible and refractory cases surgical option is the last resort. However, traditionally practiced Panchakarma and allied Ayurvedic procedures provide an opportunity for scientific validation and further modernisation.
Modern pharmacotherapy for obesity and osteoarthritis faces a concern of adverse effects, severe toxicity and long-term safety, whereas alternate therapies often lack in drug standardisation, specificity in action, and reproducibility of effects. This gap in pharmacotherapy of obesity and osteoarthritis can effectively be met with Ayurveda when addressed with reverse pharmacology approach. The short-listed leads of plants and formulations provided here can potentially be developed into globally competitive natural products for comorbidity of obesity and osteoarthritis.
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[Table 1], [Table 2], [Table 3]