New estimates suggest more than two-thirds of Americans are either overweight or obese.1 The medical significance of this statistic is astounding: Being overweight / obese is a major risk factor for type 2 diabetes, coronary heart disease, hypertension, some types of cancer, asthma, sleep apnea, non-alcoholic fatty liver disease, osteoarthritis, infertility, and metabolic syndrome.
However, not all fat is the same – visceral fat (belly fat) is much deadlier than subcutaneous fat (under the skin) and even retroperitoneal fat (outside of the peritoneal cavity).2
Recent scientific research has focused on visceral fat because of the predictive health risk factor associated with it. Abdominal fat can act as an endocrine organ and upregulate pro-inflammatory signaling molecules known as cytokines. The increased production of these inflammatory mediators seems to primarily stem from excess visceral fat.3
Health care providers are now associating this surplus belly fat with chronic low-grade inflammation, which may be the crucial factor in many chronic "age-related" disorders.4
Implementation in Practice
Throughout the past few years in practice, I have noticed a greater percentage of patients who, despite realizing they are overweight or obese, have never been educated on the dangers of abdominal fatness and its correlation to disease. During the initial consultation, I started to routinely assess a patient's "systemic health" with a simple measurement called waist circumference (WC).
Unlike measuring body-mass index (BMI), where one can be in the overweight status, but may not be at increased health risk (think athlete with increased muscle mass), WC can be used to determine central obesity.5
When I started measuring WC as an easy-to-perform, in-office diagnostic test, I noticed an immediate response by patients that encouraged them to talk more about their health and the possible impact their excess belly fat has had on them. Patients were beginning to understand that where body fat was placed within the body was more important than the actual quantity of body weight or fat.5 Patients were surprised that their primary care providers never approached this subject and therefore never felt their belly fat was ever a health concern.
The first step in bringing attention to the patient is to show them their waist circumference. I always ask permission to measure them first. Patients are typically unaware of their waist circumference and underestimate their measurement.
Measuring WC in adults is a simple task without much room for error. The great thing about WC as an anthropometric measurement is the value in assessing health risk in persons categorized as having a normal BMI, as I have measured many patients described as being thin on the outside, but fat on the inside (TOFI).6
The correct way to measure WC is to locate the top of the right iliac crest, the highest point of the hip bone on the right side. Place a measuring tape in a horizontal plane (parallel to the floor) around the abdomen at the level of the iliac crest. The tape should be snug, but should not compress the skin. Take the reading at the end of a normal expiration a few times to check for accuracy.6
Once WC is measured, I show the patient their risk, particularly if they fall into the high-risk category:7
I always approach this topic in a gentle, non-judgmental fashion. For example, I might say: "Mr. Griffin, as you can see with your current WC at 43 inches, you are now in the high-risk category." The patient can now "see" how their excess belly fat can be dangerous and perhaps want to know what you can do to help them. This ultimately increases the services you can offer and a whole other population of patients you can help.
Visual aids are very important, as I have anatomical models and posters throughout the office that show abdominal fat and how close in proximity many organs are to this fatty-deposit layer.
Getting the Patient Started
Be prepared to have a variety of treatment plans in place for this type of patient. You may need to modify your equipment and obtain some continuing education as well. In my office, I offer a variety of aerobic and weight-bearing exercises, educational literature and videos, supplements and prepackaged medical foods to facilitate a fat-loss program.
As with any patient who comes into your office, attaining success with this type of patient revolves around ongoing education and positive encouragement. In part 2 of this article, I will discuss the actual program a fat-loss candidate can undergo to decrease their visceral fat and overall health risk.
References
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
Spearheaded by burgeoning scientific and clinical research literature, psychedelics have reached a level of media coverage and popular interest that has not been seen for over half a century. By “psychedelics,” we are referring to the unique class of substances that includes psilocybin (the active compound found in so-called “magic mushrooms”), LSD, dimethyltryptamine (DMT), ayahuasca, 5-MeO-DMT, and mescaline – each of which occurs in the natural world (except for LSD, which is a semi-synthetic compound).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
