Inquisitive Understanding of Samprapti Vighatana in Primary Hypothyroidism with Obesity as a Rasapradoshaja Vikara

Introduction

Thyroid disease encompasses various conditions like hypothyroidism, hyperthyroidism, autoimmune thyroid disease, thyroid nodules, and thyroid cancer, where the function, size, or structure of the thyroid gland will be affected. Thyroid (vital butterfly shaped) gland has a significant role in basal metabolic rate, growth and plays important role in calcium metabolism. It is located in the neck (jatruurdhwabhaga), where Vishuddhi chakra, the fifth primary chakra resides.¹ It governs the functions of the thyroid and parathyroid glands. The thyroid gland secretes Triiodothyronine (T3) hormone, Thyroxine hormone (T4) and Calcitonin.

In women, the prevalence is higher, with 11.4%, than in men, in whom the prevalence is 6.2%.² In an Indian study of 625 consecutive primary hypothyroidism patients grouped in, that obesity patients were noted more; among them, overt hypothyroidism was present in 33% and subclinical hypothyroidism in 11% of subjects.³

Hypothyroidism is defined as a deficiency of thyroid hormones or a disruption of the hypothalamus-pituitary-thyroid axis.⁴  Hypothyroidism can be primary when there is thyroid gland disease or secondary to hypothalamic or pituitary dysfunction.⁴

Primary hypothyroidism or overt hypothyroidism is a condition where, due to negative feedback, there is elevated thyroid stimulating hormone >10 mU/L with free T4 level below the normal range.⁵

Hence, thyroid dysfunction, associated with decreased thermogenesis, and decreased metabolic rate further correlating with higher body mass index will lead to the high prevalence of obesity.⁶

To understand thyroid dysfunction, the following points can be considered:

Agni Importance ⁷

For basic interim body functions Prakrutha Agnithe base for life’s essentiality. The impairment of agni leads to disease formation by causing vikara at dosha, dhatu, mala levels.

Jatharagni Pramukyata ⁸

Jatharagni is the chief among all types of Agni because the functions of bhutagni and dhatvagni depend on this. Aggravations and diminution of jatharagni result in aggravations or diminution of bhutagni and dhatvagni.

Agni and Pitta interpretation ⁹

Agni itself is included in pitta and  the body, it is responsible for producing a wholesome or unwholesome effects, vitiated or non-vitiated states respectively, like digestion - indigestion, vision - nonvision, proper degree or improper degree of heat, normal-abnormal complexion, lack of skill/ability, anger-exhilaration, confusion, and clarity.

Role of Pitta in Agnimandhya¹⁰

The Pachaka pitta is situated  between Amashaya and Pakwashaya i.e., Grahani. It is responsible for Pachana and Vivechana of Chaturvidha Annapana and hence called Pachaka agni, which is regarded as the master of all Agni’s as it controls all the Dhatvagni and Bhootagni. Pachakaka pitta has an important role in causing Agnimandya.

Dhatvagni and Jatharagni relation¹¹: Acharya Vagbhata has given a direct relation between Dhatvagni and Jatharagni. All the respective dhatu have the elemental part of jatharagni. So, with jatharagni impairment, dhatvagni also gets manda or dipta and causes dhatu vriddhi or kshaya, respectively.

With the detailed Amshamsha Kalpana analysis of Nidana in Primary hypothyroidism with Obesity, we can understand aaharaja, viharaja, manasika factor makes Vata, Kapha prakopa and Pitta kshaya. Even Rasavaha and Medovaha srotas involvement in the vyadhi manifestation can be understood.

Agni and Thyroid Hormones

Functions of Agni and its presentations in Hypothyroidism

• Paka or Kshudha can be compared to calorigenic action, increase in enzymatic secretions, regulation of carbohydrates, proteins and fat metabolism and movements of the GI tract. In hypothyroidism, presentations like less appetite, bloated, and constipation can be observed when affected.
• Bala can be compared to normal activity of skeletal muscles. In hypothyroidism presentations like weakness of muscles or muscular-pain and stiffness can be noticed when affected.
• Utsaaha can be considered important for the normal sexual function, interest, desire.When affected in hypothyroidism shows features of loss of libido,lethargy and fatigue.
• Maatratva or Ushma helps in inducing thermogenesis, and in hypothyroidism cold intolerance can be observed when thermogenesis is affected.
• Medha can be considered as a good, healthy state of brain functions, and in hypothyroidism, confusion, delirium, and anxiety features can be observed.
• Varna can be considered in maintaining erythropoiesis functions, where, when affected, shows features of pallor in hypothyroidism.
• Upachaya can be considered with the actions of growth and development where when affected shows features of weight gain or loss in hypothyroidism.

Relation of Dhatwagni functions with thyroid hormones

• Rasaagni’s function is Preenana and can be related to metabolic functions, vasodilation by maintaining the blood flow.
• Raktaagni’s function is Jeevana, which can be correlated to the action of erythropoiesis by thyroid hormones.
• Maamsaagni’s function is Lepana, which can be correlated to  regular skeletal activity of muscles by the influence of thyroid hormones. 
• Medhoagni, function is snehana, can be correlated with maintaining body weight by the influence of thyroid hormones.  Significant involvement in lipid metabolism like maintaining cholesterol, triglycerides levels in plasma.
• Asthyagni’s  function is Dharana, thyroid hormones help close epiphysis.
• Majjagni, does poorana, thyroid hormone function influence the stimulation of the nervous system.
• Shukraagni does garbhotpadana, a thyroid hormone that influences normal sexual function, and maintains hormone levels.

With the above analysis of Dhatu, Dhatwagni and its clinical presentations, we can understand the variations in the basic metabolism, erythropoiesis, lipid metabolism, skeletal health, nervous system cognitive functions, and reproductive system functions will be impaired in primary hypothyroidism with obesity.

The  primary function of thyroxine is to stimulate basal metabolic rate. Thyroxine acts as a catalyst for maintaining cellular oxidative processes throughout the body. Hence, it has a profound influence on tissue metabolism all over the body.Thyroxine, are under the control of jaṭharagni and Dhatvagni, as per Ayurveda. Jaṭharagni contributes itself to Dhatu formation with ahara paka kriya. The jaṭharagni present in Dhatu (Dhatvagni) when hyperactive leads to Dhatukshaya, and when hypoactive leads to vruddhi of Dhatu.¹¹ These points can be illustrated by hyper and hypometabolism which are associated with hyper and hypofunctioning of the thyroid gland. These strategical analysis of Amshaamshakalpana of Nidana, Agni (Jatharagni, Dhatwagni), Dosha, Dhatu, clinical features of primary hypothyroidism with obesity with Dosha and Srotas involvement gives us a striking similarity with the disease pathology of primary hypothyroidism with obesity as a Rasapradoshakara vikara.

 SAMPRAPTI CHAKRA:

Analysing the Samprapti, the Rasapradoshaja Vikara lakshana’s can be interpreted as follows:

Rasa dushti as:

• Gurugatrata- Heaviness of body
• Alasya- Laziness
• Galganda- Structural variations 
• Apakti- Decreased BMR
• Atisthulata- Increase in BMI
• Sheetghnata- Feeling cold

Kapha Vruddhi

• Agnisadana- Less Digestive power
• Anganam gouravam- Heaviness in the body
• Alasyam- Laziness

Pitta kshaya (Annavasrotodushti lakshana)

• BMR impairment
• Thyroid hormone secretions impairment

Vata Vruddhi

• Shakrut graham- Constipation
• Bala bramsha- Loss of strength- weakness
• Indriya Bramsha-Debility of sense organs affecting intellect concentration etc.

Meda vruddhi

• Shramam- Weakness
• Swalpe api cheshtite shwasam- Exertional dyspnoea
• Spik, sthana, udara lambana- Weight gain

When with Ama lakshana/ Bahudoshaavastha, it exhib its:

• Balabramsha- Loss of strength
• Gourava- Heaviness in the body/ Sthoulya
• Alasya- laziness
• Mala Sangha- Constipation
• Apakti- Decreased BMR leading to primary hypothyroidism with obesity or sthoulya.

The above explanation can be interpreted with HPT,GBT, HPG axis impairment and having its role in the pathophysiology of the disease.

Discussion

Ayurveda, the science of life purely states that maintaining Samyavastha of the Agni increases the disease-free state and improves the longevity of the Life.¹ The detailed analyses of different concepts of Agni helped us to understand the symbiotic association of Agni with the enzymatic functions of the thyroid gland. As Lord Eshwara is the supreme entity, who governs and controls the universe, similarly, Jatharagni governs and controls the Kaya.¹⁷

Initially Akasha mahabhuta utpatti takes place, which is further succeeded by Vayu and Agni utpatti.¹⁸ Hence the evolution theory explains that the qualities of Akasha and Vayu are imbibed by Agni. Agni is responsible for the digestion and metabolism transformations. Analysis of Pitta dosha in relation  to Panchamahabhuta explains about the  amalgamation of Agni and Jala qualities.

Jatharagni, Bhutaagni, Dhatvaagni,  being the types of Agni are interconnected with each other in the function ality aspect.

Amshamsha Kalpana of Nidana’s of Rasapradoshaja vikara proves the aggravation of Vata (Prana, Udana, Samana, Vyana, Apana), Kapha (Avalambaka, Kledaka, Tarpaka) and Pitta Kshaya (Pachaka, Brajaka, Ranjaka, Sadhaka). Manasika factors like Chinta, Shoka, Bhaya etc shows its affects in the impairment of metabolism (Annavaha, Rasavha, Medovaha Srotas dushti). Dosha Dushya Sammurchana -Uttarottara Dhatvagni mandhya specifically Rasa and Meda. Agnimandhya and Rasavahasrotodushti features like Aruchi, Angamardha, Gourava, Apakti, Klama etc observed.

Vishuddha chakra or throat chakra that resides in kantha pradesha along with Udana vayu governs the thyroid gland functions and speech. When the energy gets blocked, person prone to eating disorders, thyroidim balance ,sore throat, speech impediments and deafness. So, this establishes interrelationship between Vishuddha chakra and Udana vayu and Thyroid gland.¹

The Gut Brain Thyroid axis is the bidirectional communication between thyroid and gut. The root cause of the disease is impaired, Gut microbiota which is governed by Agni and Pitta are affected.¹⁹

Role of HPT axis, GBT axis and HPG axis in primary hypothyroidism with Obesity²⁰

Thyroid hormones normally provide negative feedback to the hypothalamus and pituitary, helping to regulate the HPT axis. In primary hypothyroidism with obesity pathophysiology, the  low thyroid hormones result in reduced negative feedback, causing increased TSH levels. Similarly, the low thyroid hormone levels may impair the normal feedback mechanisms in the HPG axis. This can lead to altered GnRH secretion by the hypothalamus, Impaired secretion of Follicle stimulating hormone (FSH) and Luteinizing hormone (LH) from the pituitary and disruption of gonadal hormone production.

The interplay between the gut, brain, and thyroid hormones becomes disrupted in primary hypothyroidism:

Impaired thyroid function (low T3 and T4) negatively impacts gut motility and microbiome composition, leading to digestive problems, such as constipation and bloating. Altered gut microbiota can influence the conversion of T4 to T3, further impairing thyroid function and exacerbating the symptoms of hypothyroidism. Chronic low thyroid hormone levels can lead to mood disturbances, such as depression and anxiety, and cognitive dysfunction, which are often seen in individuals with hypothyroidism. Increased intestinal permeability (leaky gut) and immune activation contribute to systemic inflammation, which may worsen gut dysfunction and thyroid hormone imbalances.

In primary hypothyroidism with obesity, the thyroid gland itself is dysfunctional and cannot produce adequate amounts of T3 and T4 showing, Low T3 and T4 levels. Elevated TSH levels, as the pituitary tries to compensate for the lack of thyroid hormones by increasing TSH secretion.

Further, the HPT axis dysfunction (due to low thyroid hormone levels) can have secondary effects on the HPG axis. The hypothalamus, pituitary, and gonads are all affected by the altered thyroid hormone levels, leading to reproductive dysfunction. This includes menstrual irregularities, anovulation, and infertility in women, which can contribute to reduced fertility and sexual dysfunction. HPG axis  does not exhibit a key role in thyroid hormone regulation, the disrupted thyroid hormone levels in primary hypothyroidism can significantly affect reproductive health by interfering with the GnRH secretion, Follicular stimulating or luteinizing hormone release, and gonadal hormone production.

Thyroid Hormone Resistance in Obesity In individuals with both primary hypothyroidism and obesity, there may be a phenomenon of thyroid hormone resistance. This means that even when thyroid hormone levels are normalized (e.g., through thyroid hormone replacement therapy), the body may not fully respond to the hormone due to changes in thyroid hormone receptors or impaired intracellular signalling,especially in fat tissue and other organs involved in metabolism.

Obesity and Metabolic Effects on Primary Hypothyroidism with Obesity Reduced thermogenesis contributes to weight gain. In hypothyroidism, the body's ability to burn fat for energy is impaired, and in obese individuals, this can be even more pronounced due to metabolic inefficiencies. With low thyroid hormones,  lipid metabolism slows down, and the body stores more fat, leading to further weight gain and difficulty in losing weight.

Initially, with the detail Amshamsha kalpana about Agni, Dosha, Dhatu, Srotas, Nidana, Poorvaroopa, Roopa in understanding Samprapti. Then, along with above details of HPT, GBT, HPG axis we can try to correlate the individual factors. Further these help us to understand the entire pathogenesis of Primary hypothyroidism with Obesity as a Rasapradoshajavikara, where  basal metabolic rate decreases, which increases TSH levels.

Conclusion

With the strategic analysis of the basic concepts of Nidana, Agni, Dosha, Dhatu, Srotas the disease concept is perspicuously understood. Gut thyroid brain axis link with the basic Samprapti of vyadhi is analysed and the above interpretation can be implemented in chikitsa of primary hypothyroidism with obesity. Further clinical research in the chikitsa aspect is required to know the exact benefits over the subjects having primary hypothyroidism with obesity.

Conflict of Interest

Nil