Zhang Xijian, a famous Chinese medicine practitioner in China, discusses the pathogenesis characteristics of adolescent central obesity based on "qi change theory"

Ji-Cai Liu Cui-Yao Tang Si-Yu Lu Dan-Ping Zhu Xi-Jian Zhang

1 Hunan University of Traditional Chinese Medicine, Changsha 410000, Hunan, China

2 Department of Endocrinology, Chongqing Hospital of Traditional Chinese Medicine, Chongqing 400011, China

Keywords:Central obesity TCM pathogenesis Adolescents

ABSTRACT Obesity [1] is a group of common and ancient metabolic diseases. Central obesity is common in clinical practice. Due to the simple constitution of adolescents, their pathogenesis is simple and changeable, or there is a mixture of cold and heat, or a mixture of cold and heat, or the same disease on the surface, and the pathogenesis of traditional Chinese medicine is complex and changeable. The pathogenesis of TCM pathogenesis of adolescent central obesity is analyzed with examples to provide new theoretical ideas for the treatment of obesity by Chinese medicine.

Modern medicine believes that obesity is a common endocrine and metabolic disease caused by a series of eating regulation and energy metabolism disorders, which results from specific factors such as genetics, environment, etc.[2.] From the perspective of pathology and physiology, obesity can be divided into proliferative obesity, benign obesity, and hypertrophic obesity. Among them, only the storage of adipose cells of hypertrophic obesity accumulates, while the number of adipose cells hypertrophic obesity does not accumulate in obvious way. Its characteristic is that fat often accumulates in the central part of the body (the trunk) from middle age, which also known as central obesity [3]. Adolescent obesity refers to adolescents aged 13-25 years with a body mass index＞ 28 kg / m2 [4]. Obesity, especially central obesity, is closely related to the occurrence of diabetes, hyperlipidemia, hypertension, stroke, and coronary heart disease [5,6]. With the rapid development of the times and society and the improvement of people's living standards, the incidence of obesity in China has increased significantly [7], and the people of onset is becoming younger. Obesity has become one of the main problems affecting the physical and mental health of adolescents [8]. Traditional Chinese medicine believes that obesity [9] is a type of medical symptoms such as excessive accumulation of body adipose, abnormal weight gain, and dizziness, fatigue. Although there was no such term as central obesity in ancient times, descriptions of

obesity have long been recorded, such as "fat people", "fat noble people", "fat white people", "anointed people", "meat people", and "fullness". There are also many records of pathogenesis, such as "Su Wen · Common Commentary on the Theory of False Reality", which states that "Gan Fei is noble, but the disease is anointed", "Shi Shi Se Ji" "Fat people are sputum, but qi is deficient, and blood cannot run. Therefore, sputum is born. "At present, it is thought that adolescent obesity TCM syndromes can be roughly divided into stomach heat and dampness, spleen deficiency and dampness, liver stagnation and qi stagnation, and yin deficiency and internal heat [10], which are relatively simple and rough. Therefore, indepth study of traditional Chinese medicine in the treatment of the pathogenesis of obesity, and it is necessary to establish a treatment plan with outstanding curative effect and low price. Based on his many years of clinical experience, Professor Zhang Xijian takes a different approach and believes that the pathogenesis of adolescent central obesity can be understood from the perspective of qi. to promote the development of Chinese medicine in the diagnosis and treatment of adolescent obesity.

"qi" is an invisible and constantly moving substance that fills the universe and is the origin of everything in the universe, while the essence of qi is the origin of human beings [11]. The movement of qi (lifting in and out) is called qi movement, and the various changes made by the movement of qi are called qi transformation. Professor Zhang Xijian believes that the qi movement in the body shows the spatial fluidity of energy and matter, and the qi transformation in the human body shows the life phenomenon of mutual transformation between material forms (such as yin, yang, qi, blood and body fluid, etc.). Qi movement emphasizes the transformation of morphology, while qi transformation focuses on morphological transformation which is the result of the change in the movement of qi, which Professor Zhang referred to as "qi variation" for short [12]. The origin of the pathogenesis of any disease can be attributed to the impediment to the circulatory movement of qi in the spatial position, which causes the transformation of qi and essence, blood, body fluid, yin essence, and other substances cannot be performed normally, and eventually the abnormal qi movement and qi transformation result into lesions include the appearance of pathological changes. Therefore, Professor Zhang believes that "qi variation" is the most fundamental and basic level of pathogenesis of all lesions and runs through the entire process of disease. He advocates that understanding of the pathogenesis of all diseases should start with qi variation. The underlying pathogenesis of the disease, such as the imbalance yin and yang, predomination and decline of pathogenic factors and healthy qi, the disorder activity of ascending, descending, exiting and entering, and abnormal qi transformation can be recognized by the theory of qi variation. "qi variation" is the most subtle and deepest pathogenesis change and can be used as a basis or bridge for pathological changes such as meridians and collaterals, zang-fu organs and triple energizer, internal and external harmful factors, and pathogenic qi changes. In the analysis of pathogenesis, whether it is possible to grasp the qi movement and the imbalance of qi transformation are often the main points of the complete series of pathogenesis and the key pathogenesis, and also the points reflecting the depth of understanding of the pathogenesis. For adolescents, in the period of growth and development, the movement and changes of qi are at the peak time and a little external factor can make it lose the normal circulation. Therefore, Professor Zhang Xijian advocates that clinical evidence can be applied to understand adolescent central obesity from the viewpoint of qi variation theory, and its pathogenesis can be summarized as follows.

1.The multi-factor aggregation is the initial link of the pathogenesis which results into "stagnation of qi and exuberance of fire"

People in modern society adapt to the rapid development of urban science and technology, and their lifestyles are mainly characterized by less exercise, sedentary and prolonged sleep, or changes in food structure, dietary preferences, or increased work and study pressure, and sometimes staying up late. Over time, the main manifestation of qi in the body is "ascending less, descending more, exiting less and entering more", showing a state of "qi stagnation". The subtle qi of essence cannot transform due to due to stagnation, and then detains in the triple energizer, especially the middle energizer; The ancestor said: "too much qi can be formatted into fire." The dense stagnation of fire disturbs the spleen and stomach, which will lead to more appetite, increased energy intake. It would stock in a vicious cycle with the dis-transformation of stagnation of qi, which leads to the qi stagnation and fire excess, the middle energizer cannot transform. And this will increase the morbidity of central obesity. The main quad at this stage is Radix scutellaria- Rhizoma coptidis Powder (Radix scutellaria, Rhizoma coptidis, Sterile silkworm, Cicada, Turmeric, Rhubarb). Radix scutellaria and Rhizoma coptidis is to clear the pathogenic factors of dampness and heat in the upper and middle energizer and remove the "phlegm" of fat people,

Sterile silkworm is to promote clearness and decentralize fire, clear heat and resolve depression. Cicada tastes sweet and salt, which can clear heat, resolve poison. Both of them the smell of symplectic cool all rise, turmeric line qi and resolve depression, jet and rhubarb heat purging fire, making the heat in the solution, and rhubarb can have diarrhoea turbidity, phlegm turbidity in the body can from the valleys, SiYao mixed, make the person change and muggy.The four medicines can rise and fall, making the air machine smooth and stagnation. However, at this time, it is also necessary to pay attention to disease and solar terms. The so-called "spring, summer, and Yang, autumn, winter, and yin", the dredge ventilator should also be consistent with the natural seasons. Cold, in autumn and winter, you need to prevent too much medication to aggravate qi stagnation.

2. The dereliction of duty is an important stage in the pathogenesis of central obesity

Middle energizer has been considered as “cardinal place” for centuries, and qi stagnation and fire excess disturb it. According to whether Yangming's stomach is involved in the development of pathogenesis, it can be roughly divided into two major pathogenesis of liver loss and spleen and stomach loss. Stagnation of fire and stagnation of the liver, dysfunction of liver and qi, and failure of spleen and stomach transport are important stages of development of central obesity. At this stage, the human air transport shows a state of focusing on the coke. "Rising without rising, falling without falling, the cardinal is unfavorable." The central axis of the central axis [13] has a disorder of air change, which results in the inability of water and moisture to become subtle substances to be distributed to all visceral and meridian joints throughout the body. However, the central axis cannot be healthy, and the circular motion of the four-dimensional flow is also hindered. Among them, the main liver is drained and the vitality of the main body is adjusted. The two coordinate and influence each other during the change of the movement of the air machine. Liver qi disorders, or depression and hyperthyroidism, weathering and dryness, or forced internal organs, abnormalities in the two stools; due to the spleen's main function, which is the day after tomorrow, the spleen is lost to rise, and the stomach qi is lost to Tongjiang. Wet stagnation endogenous, Mizutani no luck. In terms of treatment, Chaige Sini Decoction can be used as the main manifestation of liver insufficiency, and Sini Powder is the main formula of liver qi stagnation. In the recipe, Chaihu and Gegen enter the liver and gallbladder meridian to raise yang, relieve liver stagnation and relieve whiteness. Consolidate Yin and nourish the liver and soften the liver, together with Chaihu to nourish the liver and blood, to reach the liver qi, spleen Qi to relieve stagnation, relieve heat and break the knot, and raise and lower with Chaihu, can enhance the effect of relaxing the Qi machine, and improve Qingqizhuo Zhigong, licorice and spleen. The main manifestations of spleen and stomach dampness and heat are Huanglian Wendan Decoction and Sanren Decoction, the method of Chinese herbal medicine Xia Jiangni and Hewei, dryness, Poria, spleen and spleen, soothe the nerves, calm the spleen and spleen, and remove skin Regulating Qi and drying dampness, Coptis diarrhea, relieving phlegm, Zhuru clearing heat and reducing phlegm, almonds Xuanli scorching lungs, gasification is wet, white cardamom aromas are wet, the air is wide, the scorching temper is smooth, and the kernels are soak Benefits the water and strengthens the spleen, so that the damp heat can be removed from the lower coke.

3. Stagnation of fire is trapped in middle energizer, dampness, phlegm, turbidity and endogenesis of blood stasis are the initiating factors of pathogenesis and syndrome

Stagnation of fire has been trapped in the body for a long time, and the qi, yin, and yang have been damaged, so that the central focus is unfavorable, and various pathological products have appeared. The so-called "yin forming, yang gas", "God's creature, landlord into the thing. Therefore, the yang of all things, and our own qi from the yang; yin into the form of all things, and our form from the yin ( "The Yellow Emperor's Nei Jing Su Wen Ji Zhuan · Volume 2 I". "Yang took the initiative, insufficient gasification, and the accumulation of excess" qi "had no provenance; the yin was the main, and the excessive formation caused the excess" yin essence "garbage to pile up In vivo, metaplasia and transformation are not possible, which is the cause of obesity [14]. It is precisely because of the excessive accumulation of metabolic wastes in the body that the human body needs relatively normal materials for its inadequate life. The internal organs are "removed from the east and replenished with the west". Mixed, mixed with cold and heat. However, after a long illness, the righteousness changes from a relative lack to an absolute deficiency. At this time, the patient often has low appetite, fatigue, and loose stools. The nature of the pathogenesis changes from reality to deficiency, and there is a mixture of deficiency and solid. Patients often have cardio-cerebral vascular disease, diabetes. , Gout, respiratory distress syndrome and other evidence. At this stage, commonly used Lizhong decoction combined with mustard shell and Erchen decoction, white mustard seed warms the lungs, expels phlegm, clears stagnation and clears collaterals, and Fritillaria cirrhosa clears heat and sputum, detoxifies and clears stagnation. Phlegm knot, Erchen Decoction is the basis of expectorant, which can dry and dampen phlegm, regulate qi and neutralize. Lizhong decoction warms the yang, while Zhongyang is full of sputum, there is no source of phlegm.

4. Long disease turns poison, long disease enters luo, long disease enters kidney to treat central sex fat come on point.

Poisonous pathogen refers to the tangible disease that consumes the righteous energy. It is suffering from scorching fire for a long time, and it is injurious to burn the sun. The cluster of pathogenic products is inevitable. Consumption of the righteousness is inevitable. Famous old doctor of traditional Chinese medicine Tong Xiaolin once mentioned that "heavy doses can only make you simmer", Zhang Jingyue of the Ming Dynasty also said "medicine for the treatment of diseases, which is precious and special, especially brave ... but use one taste as the king, two or three tastes" In order to ambassadors, we will use big doses to get better and better. What is the way to use a husband? It depends on its strength, and if it is harmless, use it boldly. " It can be seen that although the prescription of traditional Chinese medicine is expensive and specialized, it still needs dialectical treatment. What medicine is used, what disease is used, and what amount is used, it needs to be flexibly added and subtracted. Based on the characteristics of the pathogenesis of chronic illness, injury, Zhengluo and Huadu, at this stage, Fuzheng Decoction (Astragalus, Atractylodes, Ligustrum lucidum, Lycium barbarum, Cynomorium) is used to nourish qi and nourish Yin, and Zuo Sansheng Tongluo Yin (Tiannanxing, White aconite, whole scorpion, centipede, Pinellia ternata, Fritillaria cirrhosa, Curcuma zedoaria, Radix Chinensis, Coix seed) dissolves phlegm, clears collaterals, and detoxifies and disperses medicine.

5. The patient case

Lu xxx, male,24 years old, first visit on December 17,2018, longterm obesity, multi-food easy hunger, fear of cold, neck and shoulder stiff pain, face flushed baking hot feeling, morning dry mouth bitter, self-conscious mouth often sticky greasy, no obvious abnormal urine, the current weight of 125 kg, waist circumference 105.6 cm. has a history of hypertension and takes anti-hypertensive drugs for a long time. Physical examination: tongue red, thin yellow fur slightly dry cloth tongue face, pulse depression small strength. TCM syndrome differentiation: Qi stagnation fire, dampness stagnation mutual syndrome. Prescriptions: cicada slough 10g, patchouli 10g, turmeric 10g, stiff silkworm 10g, cooked rhubarb 3g, North Bupleurum 10g, Radix Puerariae 30g, Atractylodes 10g, Atractylodes chinensis 10g, Pericarp 10g, Coix seed 50g, Raw Hawthorn 15g, Raphani 30g, Scutellaria 15g, Rhizoma Coptidis 10g, Shizhiming 30g, Oyster 30g, Trichosa powder 15g, Prunella vulgaris 30g, Rhizoma albicans 10g. Professor zhang clinical focus on the combination of disease syndrome," four diagnosis of ginseng, pulse diagnosis as the first ", first of all, cicada slough, silkworm, turmeric, cooked rhubarb clear solution of depression and heat, with Atractylodes, Magnolia officinalis flat stomach powder bitter dryness and dampness, Huoxiangfangxiang spleen dehumidification, Chen skin bitter reduce spleen phlegm, semen Raphani, Hawthorn to eliminate the causes of depression and fire inside the cause, Bupleurum to increase the effect of soothing liver qi, stone, oyster, summer grass heat prevention and treatment, Radix Scutellaria, Radix Scutellaria, Radix Scutellariae, Radix Scutellaria, Radix Scutellariae, Radix Scutellaria, Radix Scutellariae, Radix Scutellariae, Radix Scutellariae, Radix Scutellariae, Radix Scutellariae, Radi The patient then repeated visits many times, the prescription is basically unchanged, strengthen the regulating unobstructed Qi machine, clearing away heat and resolving phlegm, Shaozuo Fuzhengqi, Atractylodes macrocephala, etc., follow up in May, the patient's self-reported weight is about 25 kg lower than the first visit.

qi refers to the movement of qi, the body of qi is a continuous movement and has a strong vitality of the extremely subtle material, its flow throughout the body, outside the bones and bones of the fur, inside to the viscera, play its physiological role, stimulate and promote the body's various life activities. The movement forms of the gas engine are generally divided into ascending, descending, exiting and entering [15]. Rising refers to the movement of qi from the bottom up, falling refers to the movement from the top down, the movement from the inside to the outside, and the movement from the outside to the inside. The rise and fall of qi movement, exit and entry are contradictory and unified movements, and widely exist in the interior of the body, and the rise and fall must be balanced in order to carry out normal life activities and play its role [16]. In Su Q. Six Minor Ideas, it is mentioned that "if you go in and out of waste, you will be destroyed, and if you raise your interest rate, you will be in danger. Therefore does not go in and out, does not have the growth strong old; does not rise down, does not have the growth transformation collection. Therefore, the rise and fall of qi is the basis of human life activities [17]. whereas central obesity is caused by excessive accumulation of fat in the body, resulting in the imbalance of body ups and downs, and then a series of complications [18]. But the youth, its growth and development is more vigorous, its movement is more active, also easy to be affected by the external factors and the phenomenon of imbalance. Therefore, from professor zhang xijian's "qi change theory" point of view to understand the complications caused by juvenile center obesity, generally divided into the following aspects.

5.1 Type 2 diabetes

Relevant studies have shown that about 75% of obese people have type 2 diabetes, and 90% of patients with type 2 diabetes have increased weight before the onset of the disease [19]. Compared with other parts, internal fat decomposition speed faster, so the central obese patients with a large number of free fatty acids and glycerol are generated by dissociation, with the increase of free fatty acid and the oxidation of fat, sugar storage and reduce oxidation, mediated by insulin sugar damage occur dysplasia, insulin sensitivity decreased significantly in the body, leading to insulin resistance and high insulin hematic disease, when central obese people cannot compensate insulin resistance in diabetes mellitus [20].

5.2 Disorder of lipid metabolism

Central obesity is generally accumulate fat in the abdomen, and relative to other parts of the belly fat cells, more sensitive to lipid soluble, lipolysis resistant to insulin is low, so the central obese fat dissolve quantity is more, at the same time into the portal vein, the marked increase in the amount of free fatty acids can also make the increase in the number of synthesis of triglycerides in the body and eventually lead to lipid metabolism disorders.

5.3 Metabolic syndrome

Central obesity is considered to be an important factor leading to metabolic syndrome [22]. An important central link of metabolic syndrome is insulin resistance, and central obesity can affect the generation and development of insulin resistance [23]. Meanwhile, the inflammatory response and adipokines secreted by adipose tissue in central obese people can also trigger metabolic syndrome.

5.4 Coronary heart disease

The investigation results showed that the obesity rate of patients with coronary heart disease increased significantly, and the mortality rate was positively correlated with obesity indicators such as waist circumference, BMI and waist-to-hip ratio. Moreover, when the waist circumference of men was higher than 102 cm and that of women was higher than 88 cm, the incidence of coronary heart disease increased significantly [24]. Central sex is obese person abdominal adipose accumulation, cause the lipid metabolism disorder of the organism, with the occurrence of coronary heart disease and development closely related.

5.5 Gallbladder disease

Epidemiological studies have shown that obesity is related to the formation of gallstone, and obesity is one of the main factors leading to gallstone, which can significantly increase the incidence of gallstone [25]. The results showed that the probability of gallstone occurrence was about 250/100,000 per year when BMI was lower than 24kg /m2, but the incidence gradually increased when BMI increased significantly to 30kg /m2, and accelerated when BMI was higher than 30kg /m2 [26]. The level of triglyceride of the person of central sex fat is higher, produce crystalline precipitation easily, make occurrence gallbladder disease, or when reducing weight, the saturation of triglyceride is too high, make the illness of gallbladder disease aggravates.

6. Obstructive sleep apnea syndrome (OSAS)

A large number of studies have shown that OSAS is more common in obese people [27]. Central obesity chest excessive fat accumulation, happened to the chest wall compliance to reduce, the respiratory system load increased significantly, to make the body significantly lower the residual capacity of lung function, when the body is in a state of sleep, lack of lung ventilation will promote or cause apnea, bradycardia, brain dysfunction caused by more serious when taken to patients with respiratory failure, heart failure, sudden death, and so on, seriously affect the adolescents' life safety and health [28].

7. Other complications

Accumulation of abdominal fat increases inflammatory markers, such as elevated CRP levels, and is also associated with abnormally elevated uric acid levels associated with cardiovascular disease [29].From the perspective of syndrome differentiation of viscera and viscera, central obesity is a syndrome caused by deficiency of positive qi, deficiency of Yang qi, dysfunction of spleen and stomach and dysfunction of liver and kidney. Therefore, in traditional Chinese medicine, to grasp the central obesity of the origin of the deficiency standard solid for treatment, the origin of the deficiency is mainly qi deficiency, the actual standard is to sputum turbid, cream fat based; And the spleen is the source of phlegm, so the treatment is to pay attention to the liver, spleen and phlegm. It can be summarized as follows.

7.1 Traditional Chinese medicine treatment

According to traditional Chinese medicine, obesity can be caused by old age and physical decline, excessive overwork, irregular diet, and innate endowment, which is often manifested as abnormal transportation and transformation of the body's spleen and stomach, leading to endogenous phlegm and dampness, and then phlegm and blood stasis interpenetrate through skin channels and collaterals

[30]. So on treatment, often can choose XinSanZhi flow table, radix bupleuri, radix puerariae XinTong dried tangerine or orange peel, with perforated, sheen of magnolia officinalis, powder of semen raphani and governance, the radix trichosanthis XinRun fluid and qi, aromatization of ageratum, perrin, rhizoma atractylodis, spleen and stomach KaiQi wake sheen slippery ooze the coix seed, rhizoma alismatis, urine and the gas, with insect invigorate the circulation of t2dm.

7.2 Acupuncture and moxibustion treatment

Mainly to regulate waterways, tonic vitality for the law. The weakness of spleen and stomach leads to the deficiency of body energy, which limits the body's ability to regulate channels, and destroys the normal metabolism of water and liquid. Liver loss and dredge will affect the function of spleen and stomach, and acupuncture can not only soothe the liver and regulate qi, but also strengthen the function of spleen and stomach. If the body spleen and stomach function occurs abnormal, then the stomach qi does not fall, temper does not rise, resulting in weak qi and blood. During acupuncture, the principle of "loss of excess and benefit of deficiency" is adhered to to regulate the spleen and stomach functions, qi, blood and Yin and Yang of central obese adolescents [31]. Fat accumulates locally in the abdomen of the severely obese, with the umbilicus at its center. Umbilicus is shenque acupoint, the upper heart pulse, spleen and stomach, liver and kidney, through the five viscera and six fu-fu, through a hundred veins, is the only way to pass through the air, at the same time there are the spleen and stomach health, qi and blood, dreg meridian, balance Yin and Yang and other effects. Therefore, acupuncture and moxibustion in umbilical cord is the ideal treatment for adolescent central obesity, but its therapeutic mechanism has not been fully clarified, and its application in central obesity is also less. At present, western medicine is often used to treat patients in clinical practice. Although the effect is quick, the effect is not significant. A number of research data show that the combination of acupuncture and moxibustion on the basis of conventional western medicine treatment is significantly better than western medicine treatment alone, and has certain clinical reference value [32].

Teenagers’ central obesity is the common manifestation of the metabolic syndrome. Its pathogenesis of traditional Chinese medicine is not a single structure. The evolution of different stages of its pathogenesis such as in the beginning of onset, or after a longterm illness exists difference. And this difference can be reflected via the changes of qi movement and pulse and qi movement. We need to firmly grasp the clinical evidence and think it over and over again. Most importantly, we must not be partial or blind.