A few years ago, a new patient sat across from me. She was visibly nervous, sweat dripping down her temples, her hands fidgety. She adjusted her body in the chair in a way I've come to associate with SI joint pain. This patient's chief complaint was severe knee pain that began four months prior after falling off her horse.
She happened to be obese, and her doctor had insisted this pain was due to obesity, discounting her acute accident and refusing her pain medication until she began a weight-loss program. The patient felt tortured for 20 years prior in her attempts to lose weight that were futile, and although she did not yet trust acupuncture, she sat across from me defeated.
In this instance, it was undeniable that this patient would likely benefit from weight loss, but I felt a lot of compassion for her, as her knee pain was clearly a result of an injury, and we both knew that had she not been obese, she would have left that day at her doctor's office with the pain medication and appropriate treatment plan she went in for. While I was glad these circumstances brought her to my office, because I knew she would benefit from acupuncture and bypass the need for pain medication entirely, I felt great empathy, imagining how many times she must have sought treatment and been turned away or redirected to lose weight.
I have developed a few customs in my office that guide my approach to treatment for patients who are overweight. This is a huge topic that could be the basis for an entire course, but I hope to relay a few principles that account for patient dignity, effective treatment and ethical practice.
1. Let your patient decide if they want the conversation
My intake form that every new patient fills out includes the question, "Are you interested in a discussion about weight loss?" Before I even know what my new patient looks like, I know whether or not we are going to have this conversation.
When a patient checks "yes," I allow for an opportunity for it to come up organically in their initial intake, or for them to bring it up themselves; there is always an opportunity to discuss it when necessary. And if they checked "no," I consider the myriad of reasons they do not want to discuss it.
As a profession, we have the unique opportunity to spend more time with our patients than most medical professionals. We have the opportunity to learn about the whole person, not solely their chief complaint or the aspects of their physical appearance that are glaring to us. If we choose to listen, we can learn the whole story and the aspects of their lives that brought them to the current moment.
We must remember that our overweight patients lead their lives having to exhaustingly talk about their weight from a place of shame. Be the medical provider they don't have to do this with. Often patients will open up to you about their weight struggles once they trust you, but if you force the topic, you risk losing them forever and never having the opportunity to help them.
2. Always Provide differential diagnosis
As practitioners of Chinese medicine, we have the training to take a thorough intake that includes subjective and objective findings. Your patients are spending money on a treatment from you that should include proper diagnosis; if we fail to do this, we are practicing unethically.
Slapping a "spleen qi xu with dampness" diagnosis on every obese patient who walks through our doors is lazy practice. I consider what may have led to spleen qi xu, such as childhood trauma, over-exercise in an attempt to desperately lose weight, or chronic grief, resulting in a lack of circulation throughout the body.
The best part about providing differential diagnosis is that in doing so, we sharpen our abilities as diagnosticians; this is work that will bring us a continual stream of patients.
Patients are so thrilled to hear that we have an individual plan for them; that we see them a unique people, not clumped into stereotypes they might fit. What's more, when diagnosis is individuated, patients achieve better results.
3. Encourage appropriate levels of exercise and eating habits
We live in a society that is in large part driven by eating disorders. Most perpetuate this innocently and with good intention, but telling patients to restrict their food intake without proper training in dietetics or requesting a vigorous exercise regimen could worsen the situation, or worse, have dire consequences.
Start small and encourage patients to engage in daily movement. I encourage most of my patients to take a gentle walk after dinner five times a week with a loved one; not with the intention of increasing their heart rate, but with the intention of having a greater quality of life, and taking the time to feel cool air on their faces or to admire the sunset.
Find ways to help your patients achieve greater meaning in their lives in ways that encourage regular movement and engagement with the world around them, and I assure you their health will improve.
4. All Western standards of health are not applicable to all patients
Asking a patient to lose weight that they put on to protect themselves from an abusive childhood could be dangerous without proper support of mental health professionals. Refer to businesses around you when it will benefit the patient. I refer my patients to other professionals in my community all the time when their needs extend beyond my own skillset, because in most instances, our patients want all the help they can get if it's going to help them live better lives.
That said, there are numerous reasons people become overweight that extend beyond the basic Western understanding of what constitutes a healthy weight. These reasons include trauma, thyroid disorders, sleep issues, adrenal fatigue, eating disorders, chronic stress, inflammation, unhealed injuries, malabsorption of nutrients and hormonal irregularities. While some of these Western diagnoses constitute spleen qi deficiency and other more obvious diagnoses, not all of them do, and most coexist with other Chinese diagnoses or because of other diagnoses.
Points to Remember
So, while you may be tempted to bring up a patient's weight, remember it is not necessary to force a conversation they are not ready to have, and that you can always treat the underlying reasons that lead to weight gain in the first place, without ever mentioning their weight to them.
In most instances, these patients eventually will broach the conversation with you on their own once a rapport of trust has been built. That is when and how bonafide, lasting results in patients' lives are made.
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