Vol.5 Issue 1
Obesity

We asked two clinicians with diverse approaches to patient care to discuss the management of an obese patient. The participating clinicians were:
Robert F. Kushner, MD – Dr. Kushner is Professor of Medicine, Northwestern University Feinberg School of Medicine; Medical Director, Wellness Institute, Northwestern Memorial Hospital; and Medical Director, diet.com
Jennefer Radojevic, LAc – Ms. Radojevic is a faculty member at the Pacific College of Oriental Medicine, Chicago, Illinois

CASE STUDY
Mrs. Betty Fry, a 42 year-old African-American female, presents to the clinic for consultation on weight loss. Mrs. Fry mentions that she started the Atkins Diet two months ago and has lost 10 pounds. You have seen Mrs. Fry routinely for several years, and she wonders what you think of the Atkins Diet. She has tried a number of fad diets--Slim Fast, Grapefruit Diet, Sugar Busters-- all without success. You are concerned about her weight (200 lbs. prior to starting the Atkins Diet), particularly because on her last visit she had an elevated fasting blood glucose (180mg/dL) and hypertension (180/95).

Past Medical History

Overweight with history of multiple fad diets and cycles of weight gain/loss
Life style history
            Denies use of wine, hard liquor, beer
            Denies current use of tobacco products
            No structured activity or exercise patterns
Social history
            Married, 4 children (ages 3-14)
            Homemaker
            College educated, degree in English
Family history
            Family: tendency to be overweight
            Mother: history of diabetes
            Father: hypertensive with CAD
Medications
            HCTZ  12.5 mg/day
            Mavik (ACE inhibitor) 4 mg/day

Over the counter
            None at present
No use of dietary supplements/herbal therapies

Physical Assessment
            Height                                      61”
            Weight                                     190 lbs
            Pulse                                        90
            BP                                           145/90
            Waist circumference                 35.5 in (90cm)
            Body Mass Index (BMI)          35.9

Moderator:  Dr. Kushner, how would you manage this patient?

This case highlights the importance of viewing weight management as the central focus of care since all of the other presenting medical problems can be considered obesity-related co-morbid conditions and responsive to its treatment. Specifically, Mrs. Fry presents with moderate class II obesity (BMI 35.0 to 39.3) with a large waist circumference, placing her in a very high risk category. The known co-morbid conditions include hypertension and diabetes. A lipid profile should be performed to evaluate for dyslipidemia, a known component of the metabolic syndrome. It is important that Mrs. Fry understands the role that her weight plays in the management of these conditions, as well as the importance of directly treating hypertension and diabetes to prevent complications.

I applaud the patient for wanting my opinion on the Atkins Diet which indicates her desire to work with me. She needs to know that low carbohydrate diets for weight loss are a very controversial area with mixed opinions ranging from ardent supporters to vehement opponents. These polar arguments stem from the reported rapid weight loss observed among patients following these diets versus the relative lack of well-conducted research studies demonstrating long-term adherence, long-term benefits, and safety concerns. The Atkins Diet is among the most restrictive of low carbohydrate diets containing between 5% to 15% carbohydrates depending on the phase of the diet. Other lower carbohydrate diets, such as South Beach, Zone and Sugar Busters! are less restrictive and more consistent with recommended guidelines. What we do know so far from a handful of studies comparing lower carbohydrate diets to more moderate carbohydrate diets is that weight loss between groups is not statistically significant after one year. However, one study that enrolled patients with diabetes and the metabolic syndrome showed relative improvements in glycemic control, insulin sensitivity and dyslipidemia in those subjects randomized to the lower carbohydrate diet. This observation is particularly relevant to Mrs. Fry.
Regarding what to recommend to the patient at this time, the best diet is one that she can comfortably follow, fits into her lifestyle and improves her health. Rather than considering that she is “on the Atkins Diet,” she needs to adopt an eating pattern that is flexible, manageable, and includes are variety of foods and nutrients. By logging onto http://www.diet.com, she can take a test to identify the eating, exercise and coping lifestyle patterns that have caused her weight to scale up and use targeted and personalized strategies to gain back control. Along with guidance, a lifestyle plan and medications to treat her hypertension and diabetes, Mrs. Fry can reduce her risk for development of cardiovascular disease and other obesity-related co-morbid conditions.

Moderator:  Ms. Radojevic, what would your plan of care entail?
Obesity, as viewed by Traditional Chinese Medical practitioners, is in many ways consistent with that of the allopathic physician. Both agree that associated risk factors of obesity include poor eating habits, lack of exercise, heredity, and mental-emotional factors, among others.  In addition, it is widely accepted that excess weight can lead to a variety of secondary conditions, such as coronary artery disease, stroke, and diabetes, as well as respiratory and orthopedic problems.

However, unlike Western clinicians, the TCM practitioner does not strictly treat the obesity, per se, but the underlying imbalance that may have caused the excess weight in the first place. In other words, it is not just the notion of correcting eating habits and getting adequate exercise, although both are extremely important and should not be overlooked, but rather targeting each patient’s personal underlying pattern. Once the body’s balance is restored, systems will function as they ought to, the metabolism will process food properly, and excess weight will dissolve.

According to TCM principles, the development of obesity is caused by a variety of pathological changes in the body, or “patterns” as they often referred to. By far the most common pattern seen is that of Phlegm. The concept of Phlegm to the TCM practitioner is not only the mucous discharge one might expectorate from the nose or mouth, but also stagnant body fluids that congeal and lead to unwanted fat. Eating too much (particularly foods containing sugars, oils, and fats), coupled with inactivity, burdens the digestive system (the role of the Spleen in Chinese Medicine), leads to stagnation of body fluids, Phlegm, and ultimately fat.  Treatment, therefore, is to harmonize the Spleen, disencumber dampness, and dissolve the Phlegm, thus restoring the body to its proper functioning.

Food and appropriate nutrition also play an important role in the TCM practitioner’s treatment of obesity. TCM theory is that of moderation and balance; to put into our bodies (or take out) what is needed at that moment. This often means eating with the seasons or our internal climates.  The patient, Betty Fry, has been on a variety of diets, most recently Atkins, which is limiting, nutritionally unsound, and difficult to maintain. My suggestion would be that all fad diets, including Atkins, be immediately discontinued. As an alternative, a thorough investigation as to her individual pathology should be conducted and a pattern differentiated. By considering her unique presentation as well as her physical constitution, appropriate long-term eating guidelines can be established and crash diets will no longer be necessary. Mrs. Fry will learn that eating should not be a “one size fits all” diet, but rather a personal diagram that reflects her particular excesses and deficiencies.

Mrs. Fry’s treatment plan should further include regular acupuncture treatments- the insertion of fine needles in strategic points along the body and oftentimes the ears- which will clear blocked systems and pathways within her body. Acupuncture has proven invaluable for people seeking to lose chronic weight, which may have persisted despite numerous attempts at dieting. Furthermore, an herbal formula would be prescribed in an effort to dissolve Phlegm and remove excess dampness from her body, in the end decreasing her body’s tendency to hold on to adipose tissue. Oftentimes, this combination of acupuncture and herbs can render the use of diuretics and blood pressure medications unnecessary, such as the HCTZ and Mavik she currently takes on a daily basis. However, it must be stressed that TCM is not meant to replace treatment of any kind given by an MD, but rather as an adjunct or alternative option. All medications should be discontinued or reduced only after careful consideration and consultation with her medical doctor.

Because Mrs. Fry’s obesity is further complicated by her elevated fasting blood glucose levels, suggesting diabetes or a risk factor for future diabetes, as well as her diagnosis of hypertension, (and a family history of both).  It is imperative that she commit to regular treatment and take responsibility for the role she plays in her own health. This means finding an exercise routine that she finds enjoyable, accessible, and easily maintained. I would recommend Mrs. Fry try Tai Chi, an ancient form of exercise that incorporates gentle movements with controlled breathing, conditioning both the body and mind. Obese patients often find this form of exercise non-taxing, yet highly effective.

Finally, it is significant to note that TCM providers never apply an exclusive remedy or therapy from beginning to end when treating cases of obesity. We recognize the uniqueness of the body and its ability to continually change and present in different ways. Therefore, each treatment plan is routinely assessed and modified accordingly and different forms of therapy may be applied as the disease runs its course. What Mrs. Fry needs at 190 lbs may not be what she needs at 150 lbs or 130 lbs. Getting Betty to her goal weight and restoring her health is done in stages, which in turn skips the “plateau” that dieters often face. That being said, while TCM has been proven to be extremely successful in the pursuit of weight loss, patients should not be fooled into thinking that acupuncture, Chinese herbs, or any other form of therapy are sufficient unto themselves. Diet and lifestyle modifications are essential and must be incorporated into the patient’s daily life. Only then can a path be cleared to vitality, a balanced weight, and excellent health.

References
Berkow R. The Merck Manual of Medical Information, Pocket Books, New York, 1997
 
Deng T. Practical Diagnosis in Traditional Chinese Medicine, Churchill Livingstone, London, 1999
 
Flaws B. New Approaches to Chinese Medical Treatment of Obesity, Acupuncture Today 2002:3.

Foster GD, Wyatt HR, Hill JO, McGuckin BG, Brill C, Mohammed BS, Szapary PO, Rader DJ, Edman JS, Klein S. A randomized trial of a low-carbohydrate diet for obesity. NEJM 2003;348:2082-2090.

Maciocia G. The Foundations of Chinese Medicine, Churchill Livingstone, London, 1996