Until now, obesity has not been a common disease category in Chinese nei ke (internal medical) texts. In fact, I could not find it as a separate topic in any of a half-dozen contemporary Chinese nei ke books. However, due to changes in diet and lifestyle, more and more Westerners are becoming obese. As The Merck Manual says, "The prevalence of obesity in the USA is high and rising higher."1 In the past decade, the overall prevalence of obesity in America rose from 25% to 33%, an increase of one-third. Therefore, the treatment of obesity is a concern to many professional practitioners of Chinese medicine in the West.2
Attacking & Damaging Method of Losing Weight in Chinese Medicine
In Chinese medicine, there are both healthy and unhealthy, wise and unwise ways of treating obesity. When I was a student in Shanghai in the early 1980s, most Chinese medical pharmacies, especially those catering to Western tourists, had packages of various over-the-counter weight loss remedies on display. However, as one of my teachers pointed out to me, all of them damaged the righteous qi if taken for any length of time. This is because although they were made from "natural" Chinese herbs, the were comprised of either A) attacking and downward precipitating medicinals that purge essential nutrients from the body; B) dampness-seeping diuretics that may cause electrolyte imbalance and renal dysfunction; or C) exterior-resolving, yang-upbearing, yin-plundering diaphoretics, e.g. herba ephedrae (ma huang). When ma huang is used for weight reduction, it is a form of "speed." It should be obvious to all professional readers that none of these are healthy long-term solutions to the problem of obesity.
Treating Obesity Based on Pattern Discrimination
In terms of more healthy and holistic methods of weight loss in Chinese medicine, the fundamental prescriptive methodology is to bian zheng lun zhi, base treatment on the patient's personal pattern discrimination. Treatment based on a patient's personal pattern discrimination is both safe and effective because it addresses that person's own metabolic reasons for being overweight. Using this method, each patient receives their own individually tailored treatment plan, using Chinese medicinals, acupuncture and moxibustion, or diet and lifestyle modifications. Such individualized treatment based on each patient's pattern dispels evils when necessary and supports the righteous qi if needed, bringing the patient back to a health state of systemic dynamic balance. Although it is not easy to find obesity listed as a disease category in contemporary Chinese medical books, based on their extensive research, Philippe Sionneau and L Gang do present a pattern discrimination of obesity in their book, The Treatment of Disease in TCM, Volume 7: General Symptoms. In this book, Sionneau and L identify four patterns of obesity: 1) phlegm dampness brewing internally; 2) spleen qi vacuity; 3) spleen vacuity and stomach heat; and 4) spleen kidney yang vacuity.
To understand these four patterns and their disease mechanisms, one must understand that fat in Chinese medicine is considered a form of phlegm turbidity, while phlegm is made from congealed fluids and humors. According to Chinese medical theory, the three viscera that control fluids and humors in the human body are the lungs, spleen and kidneys. However, in terms of obesity, the lungs do not play an important role. Instead, the emphasis within most Chinese medical discussions of obesity is placed on the spleen. This is because the spleen controls the muscles and flesh; controls the movement of transformation of water fluids; and is the root of phlegm engenderment. If the spleen becomes damaged, such as by eating too many fatty, sweet foods and getting too little exercise, it will fail in its duty to move and transform water fluids. Instead, these will gather, collect and transform into evil dampness. If damp evils endure, over time they will congeal into phlegm (or fat). Therefore, all four of Sionneau and L's patterns of obesity involve phlegm dampness and the spleen.
In pattern number one, phlegm and dampness are mostly due to overeating phlegm- and dampness-engendering foods and not getting enough exercise. Such foods include sugars, sweets, oil and fats. In pattern number one, the patient's righteous qi is still relatively replete, and spleen qi vacuity has either not yet occurred or is not marked. In pattern number two, spleen vacuity is the main thing. All the signs and symptoms in pattern two are either phlegm damp or spleen qi vacuity symptoms. In pattern number three, the spleen has become vacuous and weak, while the stomach, due to overeating in general and overeating greasy, hot, fatty foods in particular, has become hot.3 Stomach heat produces hunger and a tendency to overeat, but spleen vacuity fails to disperse and transform the essence of food and drink taken in by the stomach. Although stomach heat helps explain the overeating, it is still the spleen that is the root of phlegm production.
Likewise, in pattern number four, the kidneys play a secondary or subsidiary role in the engenderment of phlegm dampness and, therefore, fat. The spleen is the latter heaven root, while the kidneys are the former heaven root. Former and latter heavens are mutually independent. The spleen qi's function of digestion is a type of warm transformation. Its role in digestion is likened to a process of fermentation and distillation or cooking. However, it is ministerial or life gate, i.e., kidney yang, which is the root of all yang and heat in the body. Spleen qi vacuity may lead to kidney yang vacuity, and kidney yang vacuity may lead to spleen vacuity, but no matter which way it happens, if kidney yang becomes vacuous and insufficient, the spleen qi will be even more incapable of warming and transforming water fluids. In this regard, it is significant that the most commonly used Chinese verb used to describe the elimination of pathological phlegm from the body is hua. This word means "to transform," but it also means "to melt." In the case of spleen-kidney yang vacuity, there is not only not enough qi to transform phlegm, but not enough yang to melt it.
Based on the above four patterns, the two main methods of treating obesity in Chinese medicine are to A) transform phlegm and eliminate dampness and B) to fortify the spleen and invigorate the kidneys. In most cases, some combination of these two groups of treatment principles is used. In addition, any other principles are added as indicated by the patient's personal pattern.
A New Approach to the Pattern Discrimination Treatment of Obesity
In an article entitled "Luo Si-wei's Experience in the Treatment of Obesity," Guo Yi-ran describes his teacher Luo Si-wei's methods of treating obesity.4 According to Guo, Luo Si-wei believed that this disease is mostly due to phlegm obstruction, liver depression and blood stasis. However, he related all three of these to qi stagnation. If for any reason the liver becomes depressed, it fails to course and discharge, and thus the qi becomes stagnant. Qi moves both fluids and blood. If the qi becomes stagnant, it will not move and transform water fluids. Instead, these may gather and collect, eventually congealing into phlegm. However, phlegm itself is a yin depression, which also obstructs the free flow of qi. Thus, qi stagnation may lead to phlegm engenderment, and phlegm dampness may cause or aggravate qi stagnation. In addition, since the qi moves the blood, if the qi becomes stagnant, the blood will become static. Because blood and fluids move together, fluids will likewise gather and collect, eventually congealing into phlegm. Static blood is also a yin depression that can obstruct the free flow of qi. Thus, qi stagnation may cause blood stasis; blood stasis may cause or aggravate qi stagnation; and both may engender phlegm dampness. This is why, according to Guo Yi-ran, there is a common saying: "Obese people are mostly (due to) phlegm and stasis."
Based on the above theories, Luo Si-wei discriminated three patterns of obesity: 1) phlegm obstruction and qi stagnation; 2) liver depression qi stagnation; and 3) blood stasis and qi stagnation.
Phlegm Obstruction & Qi Stagnation Pattern
Besides having a fat body, these patients commonly have signs and symptoms of phlegm exuberance, such as profuse phlegm; chest oppression; slimy tongue fur; and a slippery, bowstring pulse. The treatment principles are to sweep away phlegm and move stagnation. Once the phlegm is swept away, the qi can course, diffuse, and flow freely, smoothly and easily. The qi mechanism is free-flowing and uninhibited. This promotes the sliding disinhibtion of phlegm turbidity, and has the function of reducing fat and decreasing obesity. The commonly used medicinals that Luo Si-wei used for this purpose were bulbus allii (xie bai); bile-processed rhizoma arisaematis (dan nan xing); fructus trichosanthis kirlowii (gua lou); and pericarpium citri reticulatae (chen pi). Xie bai is acrid and warm and frees the flow of yang. It has a tendency to scatter congestion and stagnation. Dan nan xing clears, disinhibits, and transforms phlegm. According to the Yao Pin Hua Yi (Medicinal Ingredients Digested Meaning), "The bile clears the gallbladder qi, while the arisaema sweeps away bound qi." As the Ben Cao Yan Yi Bu Yi (Addenda to the Extended Meanings Materia Medica) says, "It also washes away slimy lumps from the diaphragm and chest."
Liver Depression Qi Stagnation Pattern
Patients with this pattern of obesity typically have some sort of emotional abnormality. Most patients have some degree of chest oppression; rib-side distention; a bitter taste in the mouth; and a bowstring pulse. Because the liver qi is depressed and bound, the gallbladder qi is depressed and exhausted. Coursing and discharge lose their command, and the qi mechanism does not flow freely. This leads to clearing/cleaning, losing their duty. Hence, fat turbidity is difficult to transform. Over time, this leads to obesity being engendered. For this pattern, Luo Si-wei commonly used the treatment principles of coursing the liver, disinhibiting the gallbladder, and moving stagnation. As the Xue Zheng Lun (Treating on Bleeding Disorders) says, "If wood's nature controls coursing and discharge, water and food are transformed." The liver governs coursing and discharge, and the gallbladder, the bowel of the central essence. It secretes essence juice, which enables the cleansing of fat and the transformation of turbidity. The medicinals Master Luo used for these purposes included radix bupleuri (chai hu); fructus immaturus citri aurantii (zhi shi); rhizoma cyperi rotundi (xiang fu); radix albus paeoniae lactiflorae (bai shao); and semen cassiae torae (jue ming zi). According to the Ben Cao Zheng Yi (Correct Meaning Materia Medica), chai hu is able to vitalize and lift clear yang. Hence, the great qi performs its good offices, and accumulation and stagnation are automatically transformed. It is also an essential medicinal for coursing the liver and disinhibiting the gallbladder. When combined with jue ming zi, these two medicinals clear and discharge liver-gallbladder depressive heat. When combined with xiang fu, zhi shi and bai shao, it is even better for coursing the liver and resolving depression.
Blood Stasis & Qi Stagnation Pattern
Besides having an obese body, patients exhibiting this pattern have dizziness; numbness of the four extremities; and a dark tongue with possible static spots. This is because the movement of blood is not smoothly or easily flowing. Rather, stasis obstructs the vessels and network vessels, and the qi mechanism is inhibited. Therefore, fat and turbidity collect and accumulate within the vessels. This makes the blood more viscous. If this continues over time, it cannot help but result in obesity combined with atherosclerosis. The principles Luo Si-wei used to treat this pattern of obesity were to quicken the blood; transform stasis; and move stagnation. For these purposes, he usually chose xue fu zhu yu tang jia dan shen (blood mansion dispel stasis decoction plus salvia). In that case, he used semen pruni persicae (tao ren); flos carthami tinctorii (hong hua); radix rubrus paeoniae lactiflorae (chi shao); radix ligustici wallichii (chuan xiong); radix angelicae sinensis (dang gui); and radix salviae miltiorrhizae (dan shen) to quicken the blood and transform stasis. According to the Ben Cao Hui Yan (Collected Sayings on Materia Medica), salvia "is a medicinal with a propensity for treating the blood division, where it removes stagnation and engenders the new, regulates the menses and normalizes the flow of the vessels." Modern pharmacodynamics show that dan shen can lower lipids and triglycerides within the liver. Combining it with chai hu, zhi shi, bai shao and xiang fu to course the liver, rectify the qi and move stagnation, increases its effect of reducing fat and decreasing obesity.
Conclusion
Based on my own 20+ years of clinical experience, I believe Luo Si-wei adds an important view to the Chinese medical treatment of obesity. In my experience, obese Western patients rarely have spleen vacuity without liver depression, and rarely have liver depression without spleen vacuity, especially if they are female, as are the majority of Westerners seeking treatment with Chinese medicine. When one combines the four patterns presented by Sionneau and L with the three patterns favored by Master Luo, I believe one now can discriminate and treat the overwhelming majority of patients suffering from obesity. Some patients will exhibit more signs and symptoms of the repletions of phlegm; dampness; turbidity; qi stagnation; and blood stasis. Others will exhibit more signs and symptoms of spleen qi and vacuity. Due to Lui Wan-su's theory of similar transformation and Zhu Dan-xi's theory of the six depressions, any of the above evil repletions may be complicated by transformative heat. Thus, phlegm may become phlegm heat; dampness may become damp heat; food stagnation may be complicated by heat; qi stagnation may become depressive heat; and blood stasis may become stasis heat. In addition, it is possible to have these types of transformative heat even in the face of yang qi vacuity. Blood stasis may also lead to blood vacuity, and either enduring heat evils or blood vacuity may lead to yin vacuity with eventual flaring of vacuity fire. Thus, the combinations of patterns in patients with obesity include more than the seven patterns described above. Nevertheless, if one understands these seven core patterns and their ramifications, one should be able to diagnose and treat most obese patients.
In closing, it is also important to note that it is impossible for most people to lose weight and keep it off without eating less and exercising more. Therefore, patients and practitioners should not be seduced into thinking that taking Chinese medicinals or receiving acupuncture without diet and lifestyle modifications are sufficient unto themselves to lose weight and keep it off. As Sun si-miao is reputed to have said, "First, modify the patient's diet and lifestyle and only then, if these do not effect a cure, treat with medicinals and acupuncture."
References
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