Management of Obesity/Overweight through Integrative Medicine Approach...

Overview

Definition

 

Overweight is defined as a body-mass index (BMI) over 25 and obesity as a BMI over 30 (BMI is defined as the weight in kilograms divided by the square of the height in meters). A BMI of over 25 is associated with increased health risks. However. Approximately 33% of Americans 20 to 75 years of age are overweight, and of these, approximately one-third are severely obese. For both men and women, the prevalence of overweight increases with age.

 

Etiology 

While there is no single underlying etiology of simple obesity, the excessive weight reflects an imbalance between energy input and energy output. However, genetic and environmental factors may also play a role; for example, total body fat stores and the total number of fat cells are determined genetically and can make an individual susceptible to obesity. In addition, there are a number of rare congenital syndromes in which all affected individuals are obese, such as Prader–Willi syndrome, Cushing's syndrome, Alström syndrome, Laurence-Moon-Biedl syndrome, Cohen's syndrome, and Carpenter's syndrome. 

• Genetic predisposition 
• Insulinoma 
• Hypothalamic disorders 
• Overeating 
• High-fat diet 
• Decreased physical activity 
• Prescription medications (e.g., steroids, phenothiazines, tricyclic antidepressants, antiepileptics, antihypertensives) 
• Psychological factors (e.g., disturbance in body image, reaction to separation or death) 

Risk Factors 

• Familial predisposition 
• Sedentary lifestyle 
• High-fat diet 

Signs and Symptoms 

BMI over 25 to 30 

Differential Diagnosis 

• Cushing's disease—characterized by weight gain in the face, thorax, and abdomen, but sparing the buttocks and extremities 
• Hypothyroidism (60% of patients have only a modest weight gain) 
• Hypothalamic tumors (e.g., craniopharyngiomas) 
• Stein–Leventhal syndrome (in women)—characterized by obesity, hirsutism, and infertility 
• Klinefelter's syndrome (in men)—characterized by increased adipose tissue and reduced muscle mass 

 

Diagnosis

 

Physical Examination 

After determining the level of obesity in an individual patient, it is essential to determine whether complications such as diabetes, hypertriglyceridemia, and hypertension exist. It is also important to assess an obese patient's willingness and motivation to lose weight. 

Many obese patients are content being "overweight" and do not view 30 or 50 extra pounds as a problem. In addition, careful assessment of any previous history of weight loss; factors related to the onset of obesity; details of the patient's current eating habits; emotional well-being; and the patient's weight-losing goals is essential to the success of any treatment program.

 

Laboratory Tests 

• Fasting serum glucose 
• Thyroid function tests 
• Serum cholesterol and triglycerides 

Pathology/Pathophysiology 

Android (male) fat distribution is characterized by fat distributed above the waist. Upper body fat distribution appears to occur by hypertrophy of adipocytes. 

There are higher morbidity and mortality associated with the upper body than lower body fat distribution. 

Gynecoid (female) fat distribution is characterized by fat distributed in the lower body such as the buttocks, hips, and thighs. 

Lower body fat distribution appears to occur by hyperplasia (i.e., differentiation of new fat cells). Because it is easier to reduce the size of fat cells than the number of them, people with a lower body fat distribution often have a harder time losing weight. 

• Hyperplasia of adipocytes: Even if weight is lost, the number of fat cells is fixed. 
• Hypertrophy of adipocytes: Cell size will return to normal with weight loss. 

Imaging 

• Generally not necessary for diagnosis 
• Dual-energy X-ray absorptiometry—to analyze body fat 
• Magnetic resonance imaging and computed tomography—to measure regional fat distribution 

Other Diagnostic Procedures 

• Waist measure—above 35" in women or 40" in men is abnormal 
• Waist: hip ratio—to measure abdominal girth (>0.85 in women and >1.0 in men is abnormal) 
• Body-mass index (BMI)—to measure the level of obesity (BMI of 20 to 25 is considered normal)
• Weight and height tables (does not distinguish between obesity and overweight) 
• Skinfold thickness measured by skin calipers (triceps, biceps, subscapular, suprailiac)—to estimate total body fat 
• Underwater weighing—to calculate fat-free mass and body fat. 
• Measure total body water (fixed fat-free mass (FFM) equals water mass/0.73), which is subtracted from total body weight to obtain total body fat.

 

Treatment Options:

Treatment Strategy

 

• Lifelong lifestyle changes (e.g., exercise, behavior modification) and diet modification are necessary to control weight in obese patients. Many obese patients may have consumed more calories than they metabolized in their weight-gaining phase but currently may be eating enough merely to maintain weight gained previously. 
• Health care providers must assess the risks associated with obesity on an individual basis, using the BMI and fat distribution as well as comorbidities as guides for treatment. 
• Risk assessment may be critical to the process of setting goals and providing motivation. 
• No drug treatment has been shown to be safe and effective for long-term weight loss. 
• Surgical therapies for morbid obesity include gastric bypass (Roux-en-Y procedure), or stapling and liposuction for moderate fat redistribution. 
• It is important to enroll family members, especially spouses, in any lifestyle and diet changes that will affect the interactions of the relationship. Family activities such as shopping, cooking, and eating out all have an impact on diet and caloric intake.

 

Drug Therapies 

• Diuretics—for temporary use to reduce water retention; does not reduce adipose tissue stores 
• Ephedrine (20 to 60 mg/day) plus caffeine (200 to 600 mg/day)—to transiently increase the basal metabolic rate. (These over-the-counter drugs should not be taken by patients with heart disease, high blood pressure, thyroid disease, diabetes, or an enlarged prostate.) 

Complementary and Alternative Therapies 

The main thrust of alternative therapy is increasing the basal body metabolism and addressing the behavioral component. The bottom line is to expend more calories than are consumed. Most obese people have tried many diets and are frustrated with their lack of success. 

Alternative therapies can help stabilize blood sugars, promote a custom-tailored exercise plan, and treat emotional well-being. 

Mind-body techniques can be helpful, especially in reframing the goal of weight loss to the goal of health. 

Individual treatment plans addressing family history, personal health risks, and past successes can be important information in designing a plan. It is interesting to note that rates of both obesity and eating disorders are rising rapidly. 

Behavior modification (e.g., keeping a food journal, eating a diet low in total and saturated fats, beginning an exercise program, counseling to change eating and exercise habits) can be effective. Special emphasis should be placed on what has and has not been successful in the past. 

Nutrition 

• Protein: While the standard weight loss diet is low protein, high complex carbohydrates, some people will do better with a high protein, low carbohydrate diet. Regular meals that contain the protein are important for blood sugar stabilization. In either diet, it is important to use many foods that the patient enjoys. Liberal consumption of oat bran or garlic helps lower lipids slightly. Anecdotally, some people lose weight by eating protein at breakfast, which decreases afternoon or pre-dinner gorging and cravings for sweets. 
• Fluid: Six to eight glasses daily of nonsugared, caffeine-free drinks flush toxins, and increase a sense of satiety. 
• Fiber: Increasing dietary fiber (e.g., fruits, vegetables, psyllium, chitin, guar gum, glucomannan, gum karaya, and pectin) promotes weight loss by enhancing blood sugar control, reducing the number of calories that are absorbed, and increasing satiety. 
• Allergies: Many people find that avoiding allergenic foods (wheat, dairy, soy, eggs, and citrus) allows for diuresis and improved digestion. Other allergic foods may be discovered by using an IgG ELISA food allergy test. 
• Multiple vitamins to address any dietary imbalances 
• Chromium picolinate (200 to 500 mcg one to two times per day): claimed to preferentially burn fat, proven to increase insulin sensitivity, stabilize blood sugars. Helpful in those patients with sugar cravings. 
• Vitamin C (3,000 to 6,000 mg/day) speeds up metabolism, acts as an anti-inflammatory, and is needed for cholesterol metabolism. 
• Essential fatty acids (primrose oil, 2 to 4 g/day; flaxseed oil, 1 to 3 tbsp./day): One study showed a reduction in appetite and some weight loss without dieting. Fat cravings may be exacerbated by a fatty acid deficiency. 
• Lecithin, choline, methionine: (1 g/day of each) aids proper fat metabolism and decreases fat cravings 
• Thiamine: (2.5 mg/day) plays a role in fatty-acid metabolism and may decrease ketone formation, increased ketones may play a role in excessive hunger; in order to avoid imbalance, supplement with B-complex: B1 (50 to 100 mg), B2 (50 mg), B3 (25 mg), B5 (100 mg), B6 (50 to 100 mg), B12 (100 to 1,000 mcg), folate (400 mcg/day) 
• Kelp (1,000 to 2,000 mg/day, equivalent to 250 to 500 mcg of iodine per day) may aid in weight loss, as it provides nutrients for thyroid functioning. 
• L-glutamine (1,000 mg tid) may blunt carbohydrate craving. 
• Coenzyme Q10 is important in fatty-acid metabolism, may help break down fat into energy 
• 5-Hydroxytryptophan (5-HTP; 100 to 300 mg/day) to reduce food intake by promoting satiety. Acts as an antidepressant, especially with sleep disturbances 
• Fasting: For patients who don't have diabetes, fasting, or juice fasting one day a week is helpful to reset the appetite control system.

 

Herbs 

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted. 

Ma huang (Ephedra sinica) is used to stimulate the sympathetic nervous system in order to burn more fat. It is a constituent of most OTC weight loss products (1 cup tea or 30 drops tincture/day in the morning). Reacts with cardiac glycosides (arrhythmias), MAO-inhibitors (potentiates sympathomimetic effects), and secale alkaloids (hypertension). Patients need to be warned of the side effects and only use ephedra short term (if at all). 

A combination of four to six of the following herbs can be taken tid before meals (1 cup tea or 30 drops tincture). 

• Peppermint (Mentha piperita) carminative, spasmolytic, historically to reduce appetite 
• Bladderwrack (Fucus vesiculosus) historic use in obesity 
• Parsley (Petroselinum crispum) diuretic, historic use in gastrointestinal conditions 
• Dandelion (Taraxacum officinale) diuretic, dyspepsia 
• Hawthorn (Crataegus monogyna) reduces peripheral vascular resistance, historically a sedative 
• St. John's wort (Hypericum perforatum) antidepressant, historically with nerve pain 
• Valerian (Valeriana officinalis) bitter spasmolytic, sedative 
• Milk thistle (Silybum marianum) dyspepsia, specifically for liver and gallbladder 
• Lavender (Lavandula angustifolia) carminative, spasmolytic, relaxant 
• Gentian (Gentiana lutea) carminative, digestive stimulation 

Homeopathy

 

Homeopathic remedies may be of help in treating obesity, but the constitutional remedy for the specific individual should be prescribed by an experienced practitioner.

 

Physical Medicine 

Daily exercise program: exercise is critical to maintaining weight loss. While 20 minutes of aerobic exercise a day is ideal, as little as 10 minutes/day can help stabilize blood sugar and thereby reduce cravings. 

Gentle exercise (walking, yoga, swimming, biking) can increase cardiovascular health without undue stress on joints.

Dynamic Yoga practices (weight loss programs with yoga) are effectively used.

 

Acupuncture 

Acupuncture can be used to help balance the body's metabolism, stabilize blood sugar, correct digestive disorders, control certain eating disorders, aid in the elimination and relieve stress, anxiety, and depression that may lead to overeating. 

Massage 

May be beneficial. By decreasing stress, cortisol is decreased, which will help to stabilize blood sugar and help prevent or treat diabetes. also as a passive exercise.

 

Patient Monitoring 

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A good provider-patient relationship is an essential ingredient for a successful treatment program. All obese patients must be monitored for the medical and psychological complications of obesity. 

Other Considerations 

Prevention 

Lifestyle changes are the key to successful weight loss in obese patients. Regular exercise and a long-term low-calorie diet can help to raise the basal metabolic rate (the rate at which calories are burned) and reset the set point (the weight the body tries to maintain by regulating the amount of food and calories consumed). 

Complications/Sequelae 

There is a known increase in morbidity (and mortality) associated with many of the complications of obesity. 

• Type II diabetes mellitus (adult-onset diabetes)—rare in individuals with a BMI <22
• Hypertension (blood pressure >160/95 mm Hg)— especially in patients 20% over ideal weight
• Coronary artery disease
• Hypercholesterolemia
• Hypertriglyceridemia as a result of increased insulin resistance and hyperinsulinemia
• Congestive heart failure and sudden death as a result of increased blood volume, stroke volume, cardiac output, and left ventricular end-diastolic volume
• Respiratory problems (e.g., Pickwickian syndrome, pulmonary hypertension) 
• Circulatory problems, such as varicose veins and venous stasis, which predisposes patients to venous thromboembolic disease 
• Endometrial and postmenopausal breast cancer in women, prostate cancer in men, and colorectal cancer in men and women 
• Gallbladder disease as a result of increased secretion of biliary cholesterol 
• Obstructive sleep apnea as a result of fat accumulation in the tracheopharyngeal area 
• Arthritis as a result of excess stress on joints especially of the lower extremities 
• Skin problems, such as acanthosis nigricans 

Prognosis 

• Eating and exercise habits are hard to change. Most obese patients have long histories of unsuccessful attempts to lose weight. 
• Approximately 10% to 60% of patients who attempt diet therapy are able to lose at least 20 pounds; however, only between 10% and 20% of patients are able to maintain their weight loss over time. 
• Patients should be told that losing 15 to 20 pounds is often responsible for a 10% to 25% decrease in health risks associated with obesity. 

Pregnancy

 

The complications of obesity can complicate pregnancy, resulting in increased risk for the fetus. Pregnancies in obese women should be considered high risk. 

• Gestational diabetes 
• Hypertension 
• Preeclampsia 
• Abnormally large infants resulting in difficult deliveries 
• Increase rate of cesarean sections with complications 
• Increased incidence of fetal distress and meconium staining

References: 

With regards Integrative Medicine