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Research(Article(
www.ijrap.net+(ISSN:2229–3566)!
EFFECT OF TRIPHALA GUGGULU AND PUNARNAVA MANDOOR IN THE MANAGEMENT OF
OBESITY: AN OBSERVATIONAL STUDY
Anil Mangal 1*, Uma Mangal 2, A D Jadhav 3, S N Murthy 4
1 Research Officer Scientist-3 (Ayurveda), Regional Ayurveda Research Institute, CCRAS, Ministry of Ayush,
Government of India, Jhansi, Uttar Pradesh, India
2 Consultant, Mangalam Multispecialty Ayurveda Hospital, Gwalior, Madhya Pradesh, India
3 Former Assistant director (Ayurveda), Central Ayurveda Research Institute, CCRAS, Ministry of Ayush,
Government of India, Mumbai, India
4 Assistant Director (Ayurveda), Regional Ayurveda Research Institute, CCRAS, Ministry of Ayush,
Government of India, Jhansi, Uttar Pradesh, India
Received on: 17/07/20 Accepted on: 25/08/20
*Corresponding author
E-mail: dranilmangal1@gmail.com
DOI:
ABSTRACT
Obesity has become an increasing global health problem among all socio-economic groups and leading to various complications like diabetes,
cardiovascular diseases and osteoarthritis knee which are responsible for morbidity and mortality. Ayurvedic approach is to provide solution in managing
rising cases of obesity among population. Aim of this study was to assess the clinical efficacy and safety of an Ayurvedic preparations Triphala guggulu
and Punarnava mandoor in the management of obesity through clinical sign and symptoms, body mass index (BMI), measurement of abdomen, chest,
thigh, arm circumference and laboratory investigation. Thetrial was conducted on 58 subjects aged between 12-60 years of both sexes of obesity.
Triphala guggulu 1 g (2 tablets of 500 mg) and Punarnava Mandoor 500 mg (1 tablet of 500 mg) thrice daily with lukewarm water for 12 weeks were
used in all study participants. Clinical sign and symptoms, BMI and circumference of body parts reduced from baseline to the end of the treatment in
completed 47 subjects out of 58.
Keywords: Ayurvedic medicine, Triphala guggulu, Punarnava Mandoor, Obesity, Medoroga.
INTRODUCTION
Obesity is spreading globally, not limited to developed countries.
It has emerged worldwide health problem in all socio-economic
society. It is also an epidemic condition in United States and some
European countries. Obesity is a harmful condition in which
excess body fat has accumulated to an extent resulting a negative
effect on health.1 World Health Organization (WHO) had
reported about 13% of the world’s adult population (11% of men
and 15% of women) were obese in 2016. It is estimated 40
million children under the age of 5 years were overweight or
obese up to 2018. Numerous studies clearly showed an increase
in mortality rate associated with Body Mass Index (BMI) of at
least 30 kg/m2. Individual with a BMI of at least 30 kg/m2 have a
50-100% increased risk compared with individuals with BMI 20-
25 kg/m2, due to Cardiovascular disease. Raised BMI is a major
risk factor for non-communicable diseases such as cardiovascular
diseases, which were the leading cause of death in 2012, diabetes
mellitus, osteoarthritis, some cancers. Childhood obesity is
associated with a higher chance of obesity, premature death and
disability in adulthood but in addition to increased future risks,
breathing difficulties, increased risk of fractures, hypertension
and early markers of cardiovascular disease (CVD), insulin
resistance and psychological effects in obese children.2 In 1997,
The WHO expert consultation on obesity warned of an escalating
epidemic of obesity that would put the populations of most
countries at risk of developing non-communicable diseases
(NCDs).3 Basically, obesity and the risk of associated diseases to
be associated with life style, changes in dietary pattern, physical
activity levels, elated to increasing frequencies, malfunctioning
of the thyroid, suprarenal, pituitary and testis. Excess intake of
high calorific diet is the major auxiliary causes. In Ayurveda,
Acharya Charaka has classified the drugs capable of removing fat
under the group Lekhaniya mahakashaya (group of ten scarifying
dravya) and other Ayurvedic texts also describe Sthaulya roga
which is similar to obesity. Ayurvedic drugs have been attributed
the properties of correcting the malfunctioning of the glands as
well as playing a substantial role in the cure of obesity due to
auxiliary causes.4 Present work was conducted on a combination
of Triphala guggulu and Punarnava Mandoor having anti-obesity
properties as mentioned in Ayurvedic classical texts.5-6 Although
some studies resulted in initial weight loss but most of the obese
patients eventually regained their weight and therefore an
effective means to sustain weight loss is still a major challenge,
therefore, a study was conducted by selected formulation Triphala
guggulu and Punarnava Mandoor which reported having anti-
obesity activity by using Kaphavata shamaka (pacifying Kapha
and Vatadosha), Dipana (enhancing metabolic fire), Pachana
(enhancing digestion) and Lekhana (therapeutic scrapping)
properties. The contents of Triphala guggulu are mainly Rechana
(a form of osmotic laxative), Deepaniya (promotes digestive and
metabolism capacity) and Vata shamaka (pacifying vatadosha)
properties and Punarnava Mandoor is Anulomana (mild purgative
action), Mutrala (diuretic) and hepatoprotective.
MATERIAL AND METHODS
This is an observational study based on daily OPD practice on 58
patients of age 12-60 years with complaints of Kshudha vriddhi
(frequent feeling of hunger), Trishna vriddhi (intense thirst), Ati-
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nidra (excessive sleep), Swedadhikya (excessive sweating),
Daurgandhya (bad odour), Alas (lazy), Angamarda (generalized
body ache), Kshudra shwasa (mild dyspnoea on exertion),
Gauravam (heaviness in the body), Daurbalya (weakness),
Sandhiruja (pain in the joints), Sarvanga Shoola; raised abdomen,
arm, thigh, chest circumference etc. The study was conducted at
outpatient department of Central Ayurveda Research Institute,
Mumbai for treatment. Present study was carried out in
accordance with ethical principles by following international
conference of Harmonization - Good clinical practices guidelines
(ICP-GCP).
Primary and Secondary outcome measures
Primary outcome measure of study was to evaluate efficacy of
Ayurvedic formulation Triphala guggulu and Punarnava
Mandoor in the subjects suffering from Obesity (Medoroga or
sthaulya) by assessing changes in BMI. The secondary outcome
measures were to evaluate the changes in obesity clinical
symptoms score, raised abdominal, arm, thigh, chest
circumference and pathological investigations like serum
cholesterol and serum triglycerides.
Trial interventions
Therapeutic combination of Triphala guggulu 1 gm (2 tablets of
500 mg) and Punarnava Mandoor 500 mg (1 tablet of 500 mg)
thrice daily with lukewarm water were given to the participants
for a period of twelve weeks. All the trial drugs were
manufactured by a Good manufacturing practice certified
company as per Ayurvedic Pharmacopoeia of India guidelines.
Inclusion criteria
Subjects of either sex, age between 12-60 years, having
symptoms of Obesity (Medoroga or sthaulya) and those who are
not taking any oral conventional drug were willing able to
participate in the study for twelve weeks were included in the
study.
Exclusion criteria
The subjects suffering from the complications of obesity like
diabetes, hypopituitarism, muscular hypertrophy, Cushing
syndrome and other endocrinology disorders, past history of atrial
fibrillation, acute coronary syndrome, myocardial infarction,
stroke or severe arrhythmia in the last six months. Further,
uncontrolled hypertension (> 160/100 mm of Hg), prolonged (>
6 weeks) medication with corticosteroids, antidepressants,
anticholinergics, severe renal or hepatic disorders, pregnant and
lactating woman were also excluded from the study.
Withdrawal Criteria
The subjects were free to withdrawn from the trial at any time
without the permission of investigator or any reason. Further, the
investigator could discontinue the subject if he / she develop any
adverse effect or there is non-compliance of the treatment
regimen (minimum eighty percentage compliances was essential
to continue in the study). In these cases, the actions were taken to
know the reason for the withdrawal and recorded in the case
report form (CRF).
Study Procedures
On screening visit, voluntary written informed consent was taken.
General and systemic examinations as well as bio-chemical
investigation, clinical assessment as per obesity symptoms using
the subject’s answers were graded on a quantitative scale (0 =
none, 1 = mild, 2 = moderate, 3 = severe and 4 = extreme) were
assessed. Total 58 subjects who fulfilled the inclusion and
exclusion criteria were enrolled in the study. All enrolled subjects
were given a combination of Triphala guggulu 1 gm (two tablets
of 500 mg) and Punarnava mandoor 500 mg (one tablet of 500
mg) thrice daily with lukewarm water for 12 weeks. Recruited
subjects were advised to carry on their daily activities and
exercises that they had been doing before the enrollment and also
advised to continue the same till the end of study period. Obesity
clinical symptoms were assessed using the subject’s answers
were graded on a quantitative scale (0 = none, 1 = mild, 2 =
moderate, 3 = severe and 4 = extreme) and measurement of arm,
chest, abdomen and thigh circumference at baseline and end of
the 84th day. Safety laboratory investigations were also done at
baseline and end of the 84th day. Patient’s compliance was
monitored by keeping a regular follow up of the patients by
personal contact and telephonic communication. Subjects were
advised to return empty containers of trial medicines on every
follow-up visit in order to check the drug compliance. Any
adverse event or Adverse Drug Reaction observed during
treatment period if any, were documented and its appropriate and
timely management were done and recorded in the CRF.
Follow-Up Assessment
Follow-up visits on day 14, day 28, day 42, day 56, day 70, and
day 84. On each follow-up visit, patient’s general and systemic
physical examination was done. Assessment of the clinical
symptoms of obesity by using of quantitative scale (0 = none, 1 =
mild, 2 = moderate, 3 = severe and 4 = extreme) and measurement
of arm, chest, abdomen, and thigh circumference were assessed.
Pathological investigations such as serum cholesterol and serum
triglycerides were performed at baseline and at the end of 84th
day.
Statistical Analysis
The data on qualitative parameters has been represented as n (%)
and on continues variable has been represented as mean and
percentage. The data related to chief complaints was analyzed
using Excel version 2019.
RESULTS
This study was conducted on 58 subjects. Out of these, 47 were
completed the study and eleven were dropped out due to loss to
follow up. The demographic data of 47 subjects are in (Table 1).
Mean body weight is 78.08 kg, height 1.61 meter. No significant
changes were observed at the end of treatment from baseline in
any of the vital signs i.e. pulse rate, body temperature, respiratory
rate, systolic and diastolic blood pressure.
Effect of treatment on outcomes measures
At baseline visit mean BMI was 29.91 kg/m2; which was
significantly reduced to 27.18 kg/m2 after 84 days of treatment
with these medicines (Figure 1). At baseline visit, mean
circumference of abdomen was 105.61 centimeters (cm), which
was significantly, reduced to 96.08 cm after 84 days of treatment
with these medicines (Figure 2). At baseline visit mean
circumference of chest was 100.07 cm, which was also
significantly reduced to 96.51 cm after 84 days of treatment with
these medicines (Figure 2). At baseline visit mean circumference
of thigh was 57.05 cm, which was also significantly reduced to
55.30 cm after 84 days of treatment with these medicines (Figure
2).
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Table 1: Demographic profile and baseline characteristics of study subjects (n = 47)
Variables
n (%)
Age (in years)
12-20
03 (06.39)
21-30
07 (14.89)
31-40
10(21.28)
41-50
16 (34.04)
51-60
11 (23.40)
Gender
Male
04 (08.51)
Female
43 (91.49)
Marital status
Married
42 (89.36)
Educational status
Illiterate
12 (25.53)
Read & write
35 (74.47)
Habitat
Urban
45 (95.74)
Rural
02 (04.26)
Economic Status
Above poverty Line
36 (76.60)
Below poverty line
11 (23.40)
Occupation
Desk Work
06 (12.76)
Field work
09 (19.15)
House Wife
32 (68.09)
Dietary Habits
Veg
17 (36.17)
Non-Veg
30 (63.83)
Built wise
Heavy
33 (70.21)
Medium
14 (29.79)
Shareerika prakriti
Pitta-Kaphaja
36 (76.60)
Vata-Pittaja
01 (02.12)
Vata-Kaphaja
10 (21.28)
Table 2: Effect of treatment on circumference of body parts in the subjects of Obesity (n = 47)
Region of the body
(in Centimeter)
Start of the treatment
(Mean)
End of the treatment
(Mean)
Percentage of
relief
Abdomen
105.61
96.08
9.02
Chest
100.07
96.51
3.55
Thigh
57.05
55.30
3.06
Triceps
33.02
31.78
3.75
Table 3: Effect of treatment on chief complaints in the subjects of Obesity (n = 47)
Clinical Symptoms
Start of the treatment
(Mean)
End of the treatment
(Mean)
Percentage of relief
Kshudha vridhi (frequent feeling of hunger)
04.00
02.07
48.25
Trishna vriddhi (intense thirst)
4.03
2.15
46.65
Swedadhikya (excessive sweating)
2.28
3.12
27.10
Daurgandhya (bad odour)
2.20
1.17
46.81
Ati-nidra (excessive sleep)
4.13
2.80
32.20
Hriddrava (palpitation)
4.13
1.81
56.17
Kshudra Shwasa (mild dyspnoea on exertion)
5.29
2.70
48.96
Angamarda (generalized body ache)
1.17
0.85
50.00
Gaurava (heaviness in the body)
03.00
1.31
56.33
Alas (laziness)
3.88
2.30
40.72
Daurbalya (Weakness)
2.5
1.28
48.80
Sandhiruja (pain in the joints)
4.8
2.69
43.95
Sarvanga Shoola (body ache)
4.61
2.34
49.24
Pipilakasancharvat vedana (tingling sensation)
4.2
2.03
51.66
Mutra krichhata (difficulty in urination)
0.85
0.46
45.88
Koshta baddhta (constipation)
1.50
0.66
56.00
Shaitya (feeling of coldness)
1.18
0.63
46.61
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Table 4: Assessment of pathological and bio-chemical investigation (n = 47)
Laboratory Parameters
Start of the treatment
(Mean)
End of the treatment (Mean)
Percentage of Relief
Serum cholesterol (mg/dl)
237.58
209.73
11.72
Serum Triglycerides (mg/dl)
151.13
131.15
13.22
Figure 1: Effect of treatment on BMI in the subjects of Obesity (n = 47)
Figure 2: Effect of treatment on circumference of body parts in the subjects of Obesity (n = 47)
Figure 3: Effect of treatment on chief complaints in the subjects of Obesity (n = 47)
At baseline visit mean circumference of triceps was 33.02 cm,
which was also significantly reduced to 31.78 cm after 84 days of
treatment with these medicines (Figure 2). At baseline visit, the
mean obesity clinical symptoms score was 53.75, which was
significantly reduced 30.37 after 84 days of treatment with these
medicines (Figure 3). The percentage of relief on chief complaints
like Kshudha vridhi (frequent feeling of hunger) was 48.25%,
Trishna vriddhi (intense thirst) 46.65%, Swedadhikya (excessive
sweating) 27.10%, Daurgandhya (foul smell in body) 46.81%,
Ati-nidra (excessive sleep) 32.20%, Hriddrava (palpitation)
56.17%, Kshudra shwasa (mild dyspnoea on exertion) 48.96%,
Angamarda (generalized bodyache) 50.00%, Gauravam
(heaviness in the body) 56.33%, Alas (laziness) 40.72%,
Daurbalya (weakness) 48.80%, Sandhiruja (pain in the joints)
43.95%, Sarvanga Shoola (body ache) 49.24%,
Pipilakasancharvat vedana (tingling sensation) 51.66%, Mutra
krichhata (difficulty in urination) 45.88%, Koshta baddhta
(constipation) 56.00% and Shaitya (feeling of coldness) 46.61%
was observed in the trial participants. Pathological investigation
such as serum cholesterol and serum triglycerides were changed
significantly (Table 3).
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DISCUSSION
Obesity is mentioned in Ayurvedic classics as Medoroga or
sthaulya and it is as old as the history of mankind. Acharya
Charaka described that continuous intake of causative factors
aggravate Kaphadosha and Mala dhatus due to similar properties
resultant its Meda obstruct the Srotas (functional channels) and
produce the obesity. He had also described Sthaulya is the most
hazardous amongst all the diseases.7 Description of Medo roga
remains a tremendous scope of research in the field of obesity.
According to allopathic medicine, obesity increases the
probability of various diseases and conditions,
mostly CVD, diabetes mellitus, osteoarthritis knee, obstructive
sleep apnea, certain types of cancer and depression.8 The
metabolism and endocrine glands is the functioning to create the
obesity. It is a collection of disorders characterized by defective
regulation of carbohydrate, lipids and protein metabolism. The
most common cause of obesity is excess calorie intake coupled
with physical inactivity. On the basis of studies, dysfunction of
the leptin systems plays a role in human obesity. Basically, it is
generated by a combination of excessive food intake, lack of
physical activity, and genetic susceptibility. A limited caseis
caused by genes, endocrine disorders, medications, or mental
disorder.9 The view that obese people eat little yet gain weight due
to a slow metabolism is not medically supported.10 Usually, the
obese people have a greater energy expenditure than their normal
counterparts due to the energy required to maintain an increased
body mass.11
In Ayurveda, Nidana Parivarjana (avoidance of etiological
factors), Kaphavata shamaka (pacifying Kapha and Vatadosha)
and Lekhana (therapeutic scrapping), Guru (heavy food) and
Apatarpana (depleting procedure) drugs mentioned for the
management of obesity.12 Studies was also suggested for the
treatment of Sthaulya roga by drugs having Apatarpana and
Lekhana karma properties.13 The trial drug, Triphala guggulu
contains Triphala (an equal quantity combination of Haritaki
(Terminalia chebula), Vibhitaki (Terminalia bellirica), Amalaki
(Emblica officinalis), Pippali (Piper longum) and Guggulu
(Commiphora wightii). Triphala is promote proper digestion and
absorption of food, decreased total cholesterol, triglycerides and
low-density lipoprotein cholesterol, improve circulation, relax
bile ducts, prevent immunosenescence, maintain homeostasis of
the endocrine system and increase production of red blood cells
and hemoglobin.14-15 It is a potential therapeutic agent for weight
loss and reduction of body fat.16 Pippali (Piper longum) is Katu
(pungent taste), Tikta rasa (bitter taste); Laghu (light to digest),
Sara (instability), Tikshna guna (high property), Ushna veerya
(hot potency), Madhura vipaka (sweet bio transformed),
Kaphavata Shamaka (pacifying Kapha and Vatadosha) in their
property and works against Kaphadosha and reduce the fat.17 A
study on Pippali suggests that Piperine gets absorbed very quickly
across the intestinal barrier through the intracellular pathway. It
may modulate membrane dynamics due to its easy partitioning,
so helping in efficient permeability across the barriers andkeeps
a lipid lowering effect and anti-obesity activity without any
change in appetite.18-19 Guggulu (Commiphora wightii) is Tikta
(bitter taste), Katu rasa (pungent taste); Laghu (light to digest),
Ruksha (dryness inducing), Vishada (clears channels), Sukshma
(minute), Sara (instability); Katu vipaka (pungent bio
transformed) and Ushna veerya (hot potency) in their properties.20
It is best drug for obesity.21 The second trial drug, Punarnava
Mandoor works in above context by its effect
on Srotas (functional channels) and Agni (digestive factors) by
enhancing digestive capacity as a result of
their Dipana (enhancing metabolic fire), Pachana (enhancing
digestion) properties.22 It is known to be effective in reducing
belly and hip fat through reducing the basal metabolic rate and
increases lipid metabolism in the body. Therefore, Triphala
guggulu and Punarnava Mandoor mobilized Medo dhatu (fat
tissue) from the body after Dhatu paka (transformation of Dhatu)
and Medo dhatu was converted in to Purisha (faeces) and Mutra
(urine) by Pachana of Meda (fat). Increase in Purisha and Mutra
volume resulted in Srotoshuddhi (purification of channels) and
Laghutva (feeling of lightness) in the body. Efficacy of the trial
drug was due to the combined effect on Medo dhatu (fat tissue),
Ama dosha (indigested substance), Dhatwagni (metabolic factors
located in dhatu) and Jatharagni (metabolic factors located in
digestive tract)23 through Dipana, Pachana, Kaphavata Shamaka
properties.
CONCLUSION
The present study data shows that Triphala guggulu and
Punarnava mandoor provided significant relief in obesity (Medo
roga or Sthaulya) in both the sexes. The study reveals that the
selected management is potential to reduce symptoms of obesity
(Medo roga or Sthaulya) with added advantage of being free from
adverse reaction. There were some limitations in this study as no
comparator group was taken to compare the efficacy of trial drug.
In future study, these points will be taken into account.
ACKNOWLEDGEMENT
The Authors are thankful all the patients for the participation in
the study. The Author (s) is also thankful to Director General,
Nodal Officer, senior technical officers of CCRAS for support.
All authors have no competing interest in the trial of drug.
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Cite this article as:
Anil Mangal et al. Effect of Triphala guggulu and Punarnava
Mandoor in the management of obesity: An Observational Study.
Int. J. Res. Ayurveda Pharm. 2020;11(5):
Source of support: Nil, Conflict of interest: None Declared
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