Clinical Pearls: How Do You Treat Adult Obesity in Your Practice?

© Mary Ann Liebert, Inc. DOI: 10.1089/acu.2009.0596

How Do You Treat Adult Obesity in Your Practice?

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in-crease in adipose or fatty tissue in the body to the ex-tent that it affects health.” This seems somewhat after the fact and says very little about what causes it in the first place. Refining that in Traditional Chinese Medicine terms, one might say that “obesity is an imbalance in Qi energetics in the Five Elements resulting in a derangement of fat metab-olism.” Which opens the way to surmise that element Earth must be involved somewhere because it rules fat and car-ries the color yellow. The mystery resolves itself, somewhat tamely, that if one is looking for an element that will play Aggressor on Earth, it must be Wood.1

Our etiology is at hand, then, that obesity is caused by Wood aggressing on Earth, which basically means a Liver Qi stagnated, which has caused a dysfunction in Earth ele-ment, and that is a good diagnosis, as it also gives us with the treatment, “reinforce Wood and Harmonize Earth.”

To reinforce Wood, one uses LR 3 in the left foot with an even movement. Place the patient supine, with the left leg flexed at the knee and the left foot on the flat surface in natural position. Massage the point with medium pressure until the patient reports some soreness, warmth, tingling, numbness. Insert a 36-gauge, 1.5-inch needle perpendicu-larly to a depth of 0.5. Let the needle sit there until it gath-ers Qi, i.e., the sensations of soreness, etc., become intensi-fied.

To harmonize Earth, one needles ST 36 on the right side. Insert a similar type needle into it perpendicularly. Wait un-til Qi arrives, then turn the needle in, reinforcing the mode for 20 turns, and when the needle feels “stuck” or heavy, turn rapidly 40 times by a reducing action.

Add topical points like Ren 12. If you are familiar with Japanese type thread moxa, burn 5 on each point after the needles are withdrawn. One treatment a week for 4 weeks makes 1 session. With 1 week’s rest, repeat for 5 sessions and assess. This approach carries a good prognosis with a gradual weight loss that does not relapse.

REFERENCE

1. Unschuld, PU. On Illness. In: Nan-Ching: The Classic of

Dif-ficult Issues. Berkeley: University of California Press; 1986.

Chapter 4:539 (Sixty-First Difficult issue).

Holmes Keikobad, MD, MB, DPH, Dipl Community Medicine, Dipl Acupuncture, LAc, NCCAOM 7724 East Meadowbrook Avenue Scottsdale, AZ 85251 E-mail: drholmes@cox.net

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effective-ness, as effective as needle acupuncture: painless, 0.25 J/cm2_{; convenience, handy device; time saving, 3-5 minutes}

in single therapy; and safety, non-invasive in simple obesity therapy. Patients with simple obesity are included whose BMI was greater than 27. In Taiwan, overweight and obe-sity are defined as BMI 24 and 27 kg, respectively. These cut-offs differ from Western standards as Asians have higher comorbidities and fat mass at lower BMI lev-els than whites. We treated them with gallium-arsenic handylaser (50 mW in maximal power, 785 nm in wave length, pulsed wave, Bahr frequency, RJ-Laser, Reimers and Janssen, GmbH, Germany), and 2 to 4 kg of body weight was reduced in 1 month (3 times a week for 4 weeks).

Stomach, Hunger (auricular points), ST 25 (Tianshu), ST 28 (Shuidao), ST 40 (Fenglong), SP 15 (Daheng), and CV 9 (Shuifen) were prescribed for weight loss. Daily in-take energy was recommended for obese females as the fol-lowing formula (height in cm 70)  0.6  30 kcal; and (height in cm 80)  0.7  30 kcal for obese males on reg-ular diet. It is between not active (28.66 kcal/kg) and mod-erately active (33.07 kcal/kg) persons, required to maintain their body weight. Most patients experienced lessened

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Medical Acupuncture is pleased to continue this regular feature, Clinical Pearls, which we have found to be very useful and

prac-tical to the readership. All of us are confronted with clinical challenges, especially when dealing with therapeutic strategies. We hope this ongoing collection of Clinical Pearls will be kept nearby, ready to put into action for the benefit of our patients, and even our-selves. How often do we ask our colleagues, “How do you treat . . . ?” This issue, we posed the question: “How do you treat adult obesity in your practice?” Herein lies your contributions. We trust that our readership will continue to participate in this section by either asking the questions or supplying the “Pearls.” We encourage and welcome your input. Please address your “Pearls” to our Managing Editor at RosalynR@aol.com.

Richard C. Niemtzow, MD, PhD, MPH Editor in Chief

Clinical Pearls

petites, good moods and sleep, smooth defecations, reduced body weight and fat, and slimmed waistlines from laser acupuncture. We suggest that laser acupuncture in the hands of a skilled physician can be a useful tool in controlling sim-ple obesity.

Wen-Long Hu, MD, MS Department of Chinese Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Chang Gung University College of Medicine, Taiwan Kaohsiung Medical University College of Medicine, Taiwan Chinese Medical Association of Acupuncture, Taiwan Number123, Dapi Road Niaosong Township Kaohsiung County 833 Taiwan E-mail: oolonghu@gmail.com

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consider: (1) the removal of Phlegm, (2) balancing and harmonizing metabolism, (3) treating addictive behaviors, (4) removing excess fluids (fluid retention), (5) encourag-ing/instructing the patient in proper dietetics/nutrition and regular exercise, and (6) applying auricular acupuncture. For the removal of Phlegm, the following points are indicated: ST 40x2 for generalized Phlegm accumulation, and ST 8x2 for removal of localized Phlegm. To balance and harmonize metabolism, the following acupuncture points are indicated: TE 5x2, BL 22x2, BL 39x2, CV 22, CV 23. To treat ad-dictive behaviors, the following points are indicated: PC 6x2, WEI-WEI (Figure 1) x2. To remove excess fluids, the following points may be used: LU 9x2, BL 13x2, SP 9x2, BL 20x2, KI 10x2, BL 23x2. For the treatment of adult obesity, the following auricular microsystem acupunc-ture points are indicated: Shenmen, mouth points, thyroid points, antihunger points, antiaddiction points (Figure 2), and others.

In my clinical practice, I usually use classical acupunc-ture points initially and then auricular acupuncacupunc-ture for pa-tient self-manipulation (maintenance). I typically follow up once a week for 4 weeks to gauge the response and if it is positive, I will then go to biweekly treatments for 4 months. If the patient is then having a positive response, again I will go to a once-a-month treatment for maintenance purposes. The key to treating obesity is effectively using motivation, diet, exercise, and acupuncture.

Steven K.H. Aung, MD, OMD, PhD, FAAFP, CM Clinical Associate Professor, Faculty of Medicine and Dentistry Adjunct Professor of Extension, Rehabilitation Medicine, Public Health, and Pharmacy and Pharmaceutical Sciences University of Alberta Edmonton, Alberta, Canada Associate Clinical Professor, College of Dentistry New York University New York, NY E-mail: draung@aung.com

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and Damp, secondary to Spleen deficiency, Qi and Blood stagnation, and sometimes, Kidney deficiency. A log-ical approach involves points to circulate energy such as LV 3, LI 4, tonify the Spleen/Stomach (SP 3,5, ST 36, BL 20, 21, and CV 12), resolve Phlegm (ST 40), and tonify the Kidney (KI 3, BL 23). For herbs, Spleen/Stomach ton-ics like Liu Jun Zi Tang (Six Gentleman Pills, Prosperous Farmer),1 _{and Bao He Wan (Quiet digestion)}2_{are always}

Wei Wei point

LU 7 2 cun TE 21 d A B f c b e a Ascending Helix Adrenal Point Ear Lobe Opening of Ear Canal SI 19 GB 2

FIG. 1. Addiction acupoints, including Wei Wei point on the Lung Meridian

FIG. 2. Addiction acupoints. A indicates addiction point; B, antihunger point.

useful, while specific weight loss formulas like Wu Long Pian (Black Dragon)3_{can be used in specific circumstances.}

This approach should be grounded in a comprehensive pro-gram that includes nutritional counseling, a daily exercise program, and stress reduction.

REFERENCES

1. Prosperous Farmer, K’an Herbs: www.kanherb.com.

2. Quiet Digestion, Health Concerns: www.healthconcerns.com. 3. Black Dragon, Blue Poppy herbs: www.bluepoppy.com.

Michael T. Greenwood, MD (MB), BCHIR, FCFP, CAFCI, FAAMA, FRSA Victoria Pain Clinic 103-284 Helmcken Road Victoria, BC, V9B 1T2 Canada E-mail: michaeltgreenwood@shaw.ca

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try-ing various body point schemes, I have found that auric-ular acupuncture works best for this condition. I use (on a regular basis) Shenmen, Stomach point, Endocrine point, Zero point, and the “Hunger” point on both ears. I perform 10 sessions at a 2-3-day interval and after that, I continue once a week for another 5-7 sessions. Although there are usually no dramatic changes in the BMI, one thing appears to be common to all patients: they lose their appetite and the satiety sensation is reached much easier.

The average weight reduction for the first month is around 4 kg (9-10 lb), although the best responder lost nearly 8.5 kg (almost 19 lb).

What I consider to be important is the fact that auricular acupuncture seems to somehow alter the alimentary habits of the patient, and, combined with diet and exercise, may be of real help in treating obesity

Dorin Claici, MD, PhD, LAc 5 Mercy Street 300085 Timisoara Romania E-mail: dclaici@yahoo.com Website: www.acumed.ro

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calo-ries than the body expends in energy. Diet control is an important approach in preventing and treating obesity. Besides choosing food that contains lower calories, the amount of food intake is critical. Ear acupoint magnet ther-apy is a simple method that may control appetite and food cravings.1

A 54-year-old woman presented weighing 255 lbs and wishing to reduce her body weight. At the beginning, she chose an 1800-calorie diet and then reduced it to 1500 calo-ries a day. She lost 34 lbs within 6 months. After this, she lowered her caloric intake to 1200 calories a day. But, she reported that her appetite was a problem all the time and she thought about food all day long. She started eating more and lost her previous control. Her weight loss was at a standstill and she had a tendency to again gain weight. In order to control this undesired appetite, the patient asked for help uti-lizing acupuncture. A magnet disk with 2500 gauze was ap-plied on each ear on the Thalamus point (refers to Hypo-thalamus in Chinese auricular acupuncture)2_{with adhesive}

tape (Figure). The magnets remained on her ear 24 hours a day, 7 days a week. Her appetite was controlled immedi-ately. She was able to consume only 1200 calories a day easily and lost another 12 lbs within 4 weeks.

In Western medicine, the hypothalamus is important for ingestion. It is the “hunger center” and “satiety center.” Re-search has shown that lesion of the area in the lateral hy-pothalamus, in which electrical stimulation can induce eat-ing behavior, causes refusal of food; whereas lesion of the area in certain ventromedial region of the hypothalamus, in which electrical stimulation inhibits eating behavior, elicits excessive eating and obesity.3

Hypothalamic neurotransmitters and neuropeptides are involved in the energy balance. For instance, microinjection of noradrenalin into the hypothalamus dramatically in-creases food intake; direct injection of serotonin into the hy-pothalamus suppresses food intake; and, drugs that release

serotonin from nerve endings decrease food intake and body weight. The higher centers of the brain are also involved in eating and drinking.3,4 _{The point of Hypothalamus is the}

first choice in reducing appetite and limiting food intake. If a person loses his/her appetite, stimulating the Hypothala-mus point can increase appetite. Using the ThalaHypothala-mus point is also cosmetically convenient.

Magnetic energy working on acupoints may be more use-ful than using acupuncture needles or herbal seeds.5,6 _{It is}

not aggressive and is easily accepted. As long as adequate information is provided to the users, it can become self-care therapy and may reduce the cost of medical care.

REFERENCES

1. Chen Y. Magnets on ears helped diabetics. Am J Chin Med. 2002;30(1):183–185.

2. Huang L-C. Auricular Treatment: Formulae and Prescriptions. Orlando, FL: Auricular Medicine International Research and Training Center; 2001.

3. Schmidt RF, Thews G. Human Physiology. Berlin, Germany: Springer Verlag; 1983.

4. Knobil E. Neuroendocrine control of the menstrual cycle.

Re-cent Prog Horm Res. 1980;36:53–88.

5. Xiang ZZ, Kai HJ. Biophysics of Acupuncture and Meridian

Channels. Beijing, China: Beijing Publisher; 1989.

6. Zhi C, Song ZW, Cun HM. Magnet Therapy. Beijing, China: People’s Health Publisher; 1994.

Yu Chen, MD (China), LAc Beijing Acupuncture, Chinese Herbology and Magnet Center 1401 Reisterstown Road, Suite 207 Baltimore, MD 21208 E-mail: dryuchen@hotmail.com Website: www.TheBaltimoreHealer.com

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studied. A summary of research in acupuncture treatment for simple obesity may give us an overview in this area. Firstly, various methods have been used in clinical observations. This includes classical body acupuncture, electroacupuncture, Au-ricular Plaster Therapy, magnetic acupuncture, ear acupunc-ture, and Chinese herbal medicine; 1–3_{secondly, the dominant}

studies were clinical trials and observations; 1–3_{thirdly, the}

in-dications or standards that applied in these studies were body weight (BW), body mass index (BMI); the changes in waist-line (WL) and hip circumference (HC); their ratio (WL/HC or WHR), cholesterol (TC) in indexes of blood lipid;1,2,4_lastly,

a majority of these studies were published in journals which are based on Chinese and Japanese publishers. More notice-ably, participants were of Chinese, Japanese, or Korean eth-nicity.1–4 _{In summary, a typical Chinese diet, consisting of}

vegetables plus a small amount of rice with some lean pork,

chicken, and fish or soy products as the main protein source is more difficult to be controlled in both treatment groups and controls in these studies. Such diets may play an important role in outcomes in addition to acupuncture treatments. In com-parison, the clinical trials of Chinese herbal medicine had much more convincing data in physiology and pharmacology.5,6

In my practice, I tend to use a combination of Chinese herbs and acupuncture. Dietary advice as well as exercise (e.g., walking) constitute a holistic program. Selections of female patients under 40 years of age with simple obesity were treated. The major acupoints selected were as follows: PC 6 (Neiguan), ST 40 (Fenglong), ST 21 (Liangmen), GB 26 (Daimai), SP 6 (Sanyinjiao), CV 12 (Zhongwan). The main herbs used were: Alisma Orientalis (Ze Xie), 18 g; Nelumbo Nucifera Gaertn. (He Ye); 12 g were all given as daily dosages in decoction formulas.

From my experience, better outcomes come from those with a commitment towards achieving health outcomes or goals. These groups of people had actively involved them-selves in the treatment programs. Here, I raise some un-solved points about these weight control programs: Chinese herbal medicine and acupuncture programs are likely to achieve short-term goals. However, to determine whether it may be used as a long-term program requires further re-search in addition to education of program participants about diet and exercise.

REFERENCES

1. Hsu CH, Hwang KC, Chao CL, Chang HH, Chou P. Elec-troacupuncture in obese women: a randomized, controlled pilot study. J Womens Health (Larchmt). 2005;14(5):434–440. 2. He L, Gao XA, Yu L. Forty cases of simple obesity treated by

acupuncture. J Tradit Chin Med. 2006;26(1):24–25.

3. Li L, Wang ZY. Clinical therapeutic effects of body acupunc-ture and ear acupuncacupunc-ture on juvenile simple obesity and effects on metabolism of blood lipids. (Article in Chinese.) Zhongguo

Zhen Jiu. 2006;26(3):173–176.

4. Bao F, Wang FO. Effects of acupuncture on waist circumfer-ence and body mass index in females of obesity of different

types. (Article in Chinese.) Zhongguo Zhen Jiu.

2006;26(8):551–553.

5. Guo C, Wei D, Chen H, Zeng X. A review of the study on anti-obesity therapies with traditional Chinese medicine. (Article in Chinese.) Zhong Yao Cai. 2002;25(7):534–537.

6. Tian WX, Li LC, Wu XD, Chen CC. Weight reduction by Chi-nese medicinal herbs may be related to inhibition of fatty acid synthase. Life Sci. 2004;74(19):2389–2399.

Edwin Yong Miao, MD M. Modern Traditional Chinese Medical Clinic–– Acupuncture 52 Pitt Street (Part 2) Ringwood Melbourne, Victoria 3134 Australia E-mail: edwinmiao2@optusnet.com.au

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diagno-sis:

1. I decide on a treatment plan for his/her condition ac-cording to signs and symptoms.

2. I use the “Turtle” acupuncture technique, plus SP 9 and ST 40, to address obesity. (“Turtle” is an area around the naval that looks like a turtle. It is used as a mirror for the body. The head is at Ren 12.)

3. I conduct nutritional counseling and request completion of food charts.

4. I educate my patients on the Traditional Chinese Medi-cine (TCM) concepts of obesity.

5. I provide a brochure on “Food Therapy” for Dampness.

Edward Block, LAc Healthy Body Beautiful Skin, LLC 2024-H Asheville Highway Hendersonville, NC E-mail: efblockiv@yahoo.com

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CV 4, CV 6, ST 25, ST 28, ST 36, and “fat” points by

using lumbar puncture needle. (The special needles are in small sizes. The “fat” points are the places where there is too much fat, but attention should be paid to avoid the nerves and blood vessels.) Sterilize the points first, then apply lo-cal anesthesia. Put the catgut (2-4 cm in length) in the lum-bar puncture needle and embed it in the fat layer. The points should be protected from infection by wound bandage. Catgut can only be embedded in the fat layer and not mus-cle. 2) Use direct moxibustion, the method of putting moxi-cones directly on the skin and letting it burn naturally until a patient cannot tolerate the pain. Use acupoints CV 4 and ST 36. Apply at least 3 moxi-cones on 1 acupoint every time; each cone is 1 cm in height, 1 cm in diameter. Cau-tion: if the skin is burned, protect it from infection. It is a long-term treatment so persist as long as possible.

Ma Tingting College of Acupuncture and Tuina Chengdu University of TCM 37 Shi-er-qiao Road Chengdu, Sichuan, China 610075 E-mail: matingtingcn@yahoo.com.cn