What is abdominal obesity?

Abdominal obesity refers to fat stored specifically around the abdomen. Fat stored around the abdomen and waist (also called, central adiposity, intra-abdominal fat, or central obesity) is believed to be a better predictor of weight-related diseases like atherosclerotic cardiovascular disease (ASCVD). Atherosclerotic cardiovascular disease (ASCVD) is the clinical result of atherosclerosis and may lead to myocardial infarction or stroke. Intra-abdominal fat (IAF) is also associated with increased risk of hormonal cancers (e.g. breast cancer), ovulatory dysfunction, and obstructive sleep apnea. Exactly why abdominal fat increases the risk of serious diseases like ASCVD, diabetes, and insulin resistance (IR) is not yet clear, but the association is well established.[1]

What causes abdominal obesity according to Western medicine?

Adipose tissue is a specialized energy storage system. Fatty acids, lipids, and glucose are converted to fat and stored in this tissue and then released to fuel energy needs. Adipose tissue is not just a lifeless, inert mass but is an endocrine organ. This means it actively secretes hormones. There are two basic types of fat tissue storage. Subcutaneous fat is the soft type of fat that you find under the skin all over the body. This type of fat is not associated with heart disease. The second type of fat is called visceral fat. It is more dense and stored deep in the abdomen and around your organs. The abdominal/visceral fat and the subcutaneous fat compartments are metabolically distinct from each other. The most important difference: The quantity of visceral fat is strongly associated with a risk of cardiovascular disease.[2]

The hormones insulin and leptin are called adiposity fat signals. Elevated levels of insulin and leptin act on the brain to reduce appetite. Insulin is secreted by the pancreas in response to a meal. It acts as the body’s glucose sugar and energy regulator. When a person is insulin resistant, the cell receptors on the tissues are not sufficiently sensitive to insulin, so the insulin is not able to allow glucose into the cells to be used for energy. If insulin cannot get the glucose into the cells, it puts the glucose into fat storage.

Leptin is secreted by adipose fat tissue. Like insulin, leptin is secreted in response to a meal. Leptin signals the hypothalamus in to tell it that there is enough energy stored. The response should be a decrease in appetite. When this system is working, an energy balance of fat storage and fat burning occurs without obesity. However, large amounts of insulin in insulin resistance may override the leptin signal, causing the person to remain hungry and continue eating. Insulin resistance (IR) is responsible for the increase of the dangerous abdominal and visceral fat storage. Leptin and insulin are responsible for subcutaneous fat storage.[3]

With insulin resistance, metabolism is impaired. Instead of fat being stored in subcutaneous tissues, excess energy is stored as fat in dangerous areas such as deep in the abdomen or around the liver, muscle, heart tissues, and beta cells of the pancreas. Studies show that abdominal and visceral fat accumulates very quickly when a person lives a sedentary lifestyle. Abdominal obesity is also a result of a poor diet consisting of consumption of highly processed, energy-dense foods that offer little in the way of nutrition. Further, when someone is under chronic stress, the hormone cortisol is secreted. Cortisol contributes to dangerous abdominal fat storage. Cortisol is also secreted when a person smokes. In addition, some people are genetically susceptible to insulin resistance and to abdominal and visceral fat storage.[4]

How is abdominal obesity diagnosed?

Abdominal obesity is defined as an absolute waist circumference of more than 102 centimeters (40 inches) in males and more than 88 centimeter (35 inches) in females along with a waist-hip ratio of more than 0.9 for males and more than 0.85 in women. In the scientific experiment known as the National Health and Nutrition Examination Survey (NHANES III), which included almost 15,000 people, waist circumference explained obesity-related health risk significantly better than the body mass index (or BMI) when metabolic syndrome was taken as an outcome measure.[5]

Chinese medicine & abdominal obesity

On pages 15-17 of issue #4, 2008 of Si Chuan Zhong Yi (Sichuan Chinese Medicine), Tian Xiao-yan and Sun Sheng-yun, both associated with Integrated Chinese-Western Medicine hospitals in Guangdong, published an article titled “Treating Abdominal Obesity Via the Liver.” This is one of the first Chinese articles I have seen on Chinese medicine and abdominal obesity. In this article, Tian and Sun say that, although spleen qi vacuity’s role in the development of abdominal obesity is easy to understand, there is also a close relationship between abdominal obesity and the liver. This is because the liver governs coursing and discharge, thus regulating and smoothing or easing the flow of the qi mechanism. If the liver’s function of governing coursing and discharge is normal, then the upbearing and downbearing function of the whole body’s qi mechanism is healthy. This then further promotes the pushing and moving ability of the viscera and bowels qi transformation. Hence the qi and blood of the entire body obtain free and smooth or easy flow and the channels and network vessels are freely flowing and uninhibited. In this case, engenderment and transformation are balanced and normal.

Tian and Sun explain this further by saying that the liver resides in the middle burner and governs engenderment and effusion. It fortifies and moves the central islet and upbears and downbears the three burners. Internally, it connects with the viscera and bowels, while externally, it spreads to or reaches the fleshy interstices. The liver is the pivotal viscus which has a predilection for orderly reaching. It is averse to repression and depression. By nature, the liver easily suffers from emotional disturbances causing it to lose its regulation and spreading. This then leads to liver qi depression and binding. For instance, if, due to repression, depression, worry, and fear or long-term emotional discomfort, the liver’s coursing and discharging function also become disordered, this may lead to the whole body’s qi mechanism movement becoming uneasy. In that case, liver wood may counterflow horizontally to assail the spleen whose own movement and transformation then lose their duty or function. Now the clear is not upborne and the turbid is not downborne. Instead, there is abdominal distention and fullness. Further, because the qi mechanism movement is not smoothly flowing, the movement of the construction and blood and the fluids and humors also becomes relaxed and slow and, if severe, it stops, collects, and stagnates. Thus is may transform into phlegm, stasis, grease, and fat, collecting and gathering in the flesh, skin, and interstices and resulting in the production of abdominal obesity. In particular, Tian and Sun stress the effect of emotional stress on the liver and its production of abdominal obesity. They say that worry and anxiety, repression and depression, and irritability and anger all easily result in depression and binding of the qi mechanism with subsequent loss of regulation of the function of the viscera and bowels. 

Abdominal obesity, phlegm & stasis

However, in Tian and Sun’s opinion, abdominal obesity does not just involve a liver-spleen disharmony. This condition is also closely associated with phlegm and blood stasis. In the Yuan dynasty, Zhu Dan-xi said that, “Fat people [have] lots of phlegm,” but phlegm is produced from fluids and humors. The qi moves the fluids and humors throughout the body. Therefore, if the qi moves, fluids and humors move. But, if the qi stops, as in liver depression qi stagnation, fluids collect and transform into dampness. Then, if dampness endures, it congeals into phlegm. Thus liver qi depression and binding can result in the formation of phlegm even without a spleen vacuity (at least in theory). Similarly, the qi also moves the blood. Therefore, liver qi depression and binding may also result in non-movement of the blood which congeals into stasis. Since the blood and fluids move together, if one of these becomes depressed and stagnant, so will the other over time. Thus it is Tian and Sun’s opinion that people with abdominal obesity not only manifest liver depression and spleen vacuity but also signs and symptoms of phlegm dampness and blood stasis. Certainly phlegm dampness and blood stasis are commonly scene disease mechanisms in patients with cardiovascular disease.

Treating abdominal obesity via the liver

Also according to Zhu Dan-xi, “If the qi flows normally, the fluids and humors of the entire body also follow the qi and flow normally.” Therefore, in order to treat phlegm dampness, it is very important to move the qi. If the liver qi is regulated and spreads and the spleen qi is fortified and moves, then the movement of the whole body’s qi mechanism will be freely and smoothly flowing and upbearing and downbearing will due their duty. To substantiate this, Tian and Sun cite a study in which 158 patients with central obesity were treated with a self-composed formula called Shu Gan Xiao Fei Tang (Course the Liver & Disperse Fat Decoction). This formula consisted of:

Chai Hu (Radix Bupleuri)

Zhi Shi (Fructus Immaturus Aurantii)

Dang Gui (Radix Angelicae Sinensis)

Xiang Fu (Rhizoma Cyperi)

Yu Jin (Tuber Curcumae)

Ze Xie (Rhizoma Alismatis), 12g each

Dan Shen (Radix Salviae Miltiorrhizae), 30g

uncooked Shan Zha (Fructus Crataegi), 50g

He Ye (Folium Nelumbinis), 10g

Shui Zhi (Hirudo)

Da Huang (Radix Et Rhizoma Rhei), 6g each

If there was excessively exuberant liver fire, Long Dan Cao (Radix Gentianae) and stir-fried Zhi Zi (Fructus Gardeniae) were added.

If there was rapid digestion and easy hungering, Mai Men Dong (Tuber Ophiopogonis), Yuan Shen (Radix Scrophulariae), and Shi Gao (Gypsum) were added.

If the stools were dry, Bai Zi Ren (Semen Platycladi) and Da Huang (Radix Et Rhizoma Rhei) were added.

If there was shortness of breath and edema, Che Qian Zi (Semen Plantaginis) and Hua Shi (Talcum) were added.

If menstruation was scanty, Hong Hua (Flos Carthami) and Tao Ren (Semen Persicae) were added.

If there was amenorrhea, San Leng (Rhizoma Sparganii) and E Zhu (Rhizoma Zedoariae) were added along with blast-fried Chuan Shan Jia (Squama Mantidis).

After one course of treatment with these medicinals, 88% of the cases lost weight. In addition, this formula was also very effective in lowering blood pressure and serum cholesterol.

Tian and Sun also cite various animal experiments showing that Chinese medicinals which affect the Chinese medical liver result in reductions of insulin and other serological markers associated with abdominal obesity and metabolic syndrome.

Conclusion:

When treating patients with abdominal obesity, it is important to take into account the liver’s role in such patients’ overall disease mechanisms. Because central obesity is associated with an accumulation of phlegm, dampness, and turbidity, obviously the spleen plays a major role. As it is said, “The spleen is the root of phlegm engenderment.” However, one must also consider that spleen vacuity is either due to or typically involves an element of liver depression qi stagnation. Further, blood stasis is also an important disease mechanism in the cardiovascular symptoms associated with abdominal obesity, and again, because the qi moves the blood, liver depression and blood stasis typically go hand in hand. Therefore, one should never underestimate the role of the liver in the production of abdominal obesity and its many associated conditions.

Copyright © Blue Poppy Press, 2008. All rights reserved.

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