Acupuncture as a potential approach to improving the health of women with obesity

Fung-Kei Cheng *

1New Territories, Hong Kong.

Abstract In addition to higher risks of various obstetric and gynaecological illnesses among women with obesity or who are overweight, maternal adiposity threatens the lifetime health of their offspring. Diverse treatments are provided, including complementary and alternative medicine such as Chinese medical practices. Acupuncture, a traditional Chinese medicinal method, is increasingly being applied to this health problem. This literature review analyses 25 clinical studies,involving 2407 participants aged 13-65 in Africa, Asia, the Middle East and North America. This illustrates the use of acupuncture alone or with other approaches to control body weight, obesity-induced diseases, and gynaecological health.Although positive indicators are presented, this study offers recommendations for enhancing reliability and validity in further research. It therefore suggests the use of acupuncture in dealing with obesity due to its efficacy, and economic and safety benefits.

Keywords: Acupuncture-complementary and alternative therapy, Adiposity, Chinese medicine, Narrative review,Obstetrics and gynaecology, Weight loss

Introduction

A rapid prevalence of obesity and being overweight will probably increase to around 20% and 38% of the worldwide adult population respectively by 2030 [1]. It has become the fifth leading risk of death, involving over 2.8 million adults globally every year [2]. Furthermore,more women tend to become obese than men, while the reverse occurs for those who are overweight [3]. Obesity is defined as adiposity, or excessive body fat accumulation indicated by body mass index (BMI).However, the index varies among regional statistics:North American adults with a BMI of 25 or over are classified as overweight, with a BMI of at least 30 indicating obesity; the respective BMI for Asians are 23 and 25; are 26 and 32 correspondingly for Pacific Islanders [4-5]. Obesity largely results in biological,environmental, and lifestyle influences [6-8].

Obesity threatens women’s physical health, incurring chronic illnesses. For instance, diabetes, stroke, and cardiovascular diseases [9-12]. Furthermore, it also causes gynaecological diseases such as breast cancer,polycystic ovary syndrome, menopausal symptoms,menstrual irregularity and dysmenorrhea [13-18]. Equally worrying are mental disorders, for example, depression,which are not rare among obese women [19-20]. These perils result in a shorter life expectancy and significantly higher health costs [21-22]. Research also raises the alarm that maternal obesity not only induces miscarriage or peri-natal complications more easily, which causes anxiety in pregnant women, but also affects long-term infancy health among foetuses, and from juveniles to adults, and includes adolescent cardiovascular diseases and autism [23-27].

Sophisticated strategies are offered for obesity management [28]. Pharmacy is usually used in reducing weight for obese women and even pregnant women who are overweight or obese, and even bariatric surgery is an option [29-31]. However, side effects limit the effectiveness of these treatments [32]. Thus, non-intrusive interventions are recommended in adopting mental imagery, cognitive-behavioural therapy and lifestyle adjustments [33-35]. Diet control, such as low-calorie and vegetarian diets, can also contribute to weight loss [36].Physical exercise and dance movement therapy are likewise effective in weight reduction [37-40]. Apart from the above, complementary and alternative therapy further contributes to anti-obesity measures, for instance,caraway, and acupuncture [41-43].

Acupuncture, a traditional Chinese medical practice,has been employed for more than 3,000 years. The earliest monograph of acupuncture in China is in Zhenjiujiayijing (215-282, A.D. Jin Dynasty), which records the use of acupuncture before Jin dynasty and the experience of acupuncture treatment at that time [44]. It is a healing method that consists of inserting a needle into one or more acupoints (specific simulation points) out of 365 in 14 meridians along the body, in duration from seconds to minutes in order to activate Qi (energy flow)[45-46]. Individuals who are receiving this approach may feel sore, full, a dull pain, aching, numb, warm, and / or heavy, indicating De-Qi (energy arrival) which presents responses in the autonomic system, limbic and para-limbic system, and neo-cortical structure of the brain[47-49]. Functions include stimulation of neuro-chemical release, blockage of pain signals, and generation of cellular and molecular components [50]. Recent studies report positive indicators for a spectrum of physical and psychological disorders such as sciatica, tinnitus, immune modulation, and addictive behaviours [51-54]. Evidence shows acupuncture is inexpensive and safe with very few adverse effects even for children, the elderly, or pregnant women [55-61]. Use of this intervention for women’s health is growing [62].

Acupuncture has been developed for diverse practices.Auricular acupuncture utilises the theory that reflex points on the ear stimulate corresponding body parts [63].With the aid of advanced technology, electro-acupuncture and laser acupuncture have also been developed [64-65].Acupuncture always combines with other Chinese treatment measures. Cupping is applied on the skin over specific acupoints by a thinned air glass to produce a partial vacuum resulting from heat inside a glass, to conduct treatment through hyperaemia or homeostasis[66]. Massage is the systematic rubbing of muscle,exerting heat to enrich the veins, lymph vessels, and nerve activity [67]. Chinese herbs have obvious efficacy for diseases [68]. Moxibustion uses a burning moxa stick to generate warmth on acupoints, which when combined with acupuncture couples to form a warming acupuncture[69-70].

In analysing the usefulness of acupuncture in coping with obesity that looms over women’s health, this literature review offers an overview of the outcomes demonstrating how this method can be employed alone or with other approaches. It provides choices, such as adjunct therapy, to patients and medical care professionals.

Research method

This review adopts 27 major electronic databases from ProQuest, including Biological Sciences, British Nursing Index, MEDLINE, PsycARTICLES, and PsycINFO, by inputting the keywords “acupuncture”, “woman” and“obesity or weight control or weight loss”. Twenty-nine works were listed. Additionally, two Chinese databases -the China National Knowledge Infrastructure and Taiwan Electronic Periodical Services - were searched, by keying in “針灸”, “女” and “肥胖 or 癡肥 or 減肥”,enumerating 62 works. The inclusion criteria selected clinical human-based studies of acupuncture, and full texts (including online first publications) published prior to May 2017 in peer-reviewed, scholarly journals.However, duplications, literature reviews, book reviews,dissertations, editorials, and commentaries were excluded.

Findings and discussion

In accordance with the eligibility criteria, 25 projects (n =11 in English, n = 14 in Chinese) were reviewed,covering 2407 women, aged 13-65, in China, Egypt,Korea, Taiwan, Thailand, Turkey, Sudan, and the USA(refer to Table 1).

Table 1 Analysis of the reviewed 25 studies

Source Research objective(s)Method design Sample size Intervention Results Research location unspecified total sessions.Reductions in BMI, degree of obesity, body fat percentage,and waist circumference.Decreases in serum TC, TG, low LDL-C.An increase in HDL-C.Pang Z,Liu Z, Xu B [77]Zhang Q,Duan W,Li N, et al.[78]Liu H, Liu T [79]To examine the effects of warming acupuncture and ear acupuncture on obesity with hyperlipidemia.To investigate the effect of electro-acupunct ure on obesity with breast hyperplasia.To investigate the effects of warming acupuncture on obesity among menopausal women.130 women,aged 18-54.67 women,aged 16-58.91 women,aged 43-54.Randomly distributed to the warming acupuncture and ear acupuncture (n = 65,aged 19-54), and warming acupuncture (n = 65,aged 18-54) groups.30-minute session,total 45 sessions.30-minute session,total 45 sessions.30-minute session,total 36 sessions.Effect rate: 95.4% in the acupuncture and ear acupuncture group, 84.6% in acupuncture group.Reductions in body weight,BMI, degree of obesity, body fat percentage.Decreases in serum TC, TG,LDL-C.An increase in HDL-C.Effect rate: 95.5%.Reductions in body weight,BMI, chest circumference, waist circumference, hip circumference, thigh circumference, waist-hip ratio.Effect rate of obesity: 88.4%.Reductions in body weight,BMI, body fat, and degree of obesity.Effect rate of menopause:99.1%.Significant reductions in Kupperman menopausal index,follicle-stimulating hormone.China China China Set T,Cayir Y,Pirim ABG [80]To examine the effects of ear acupuncture on the obese women with depression.24 women,unspecified age range.15-20 minutes per session, total 6 sessions.No reduction in BMI and depression. Turkey Yang YC,Kim JI,Kim KW,et al. [81]Ren B[82]To investigate the effects of acupuncture on heart rate variability in obese premenopausal women.To examine the effects of warming acupuncture and ear acupuncture on dysmenorrhea with obesity.46 women,aged 21-54.87 women with primary dysmenorrh ea.Unspecified age range.Randomly distributed to the acupuncture (n =23), and sham acupuncture (n = 23)groups.30-minute session,unspecified total sessions.Divided into the dysmenorrhea (n =44, aged 18-45), and dysmenorrhea with obesity (n = 43, aged 17-44).30-minute session,total 90 sessions.Reductions in body weight,BMI, waist circumference.Deactivation of parasympathetic function and an increase in sympathetic activity.Effect rate (10 sessions): 97.7%in dysmenorrhea group, 72.7%dysmenorrhea with obesity group.Effect rate (20 sessions): 100%in dysmenorrhea group, 86%dysmenorrhea with obesity group.Effect rate (30 sessions): 100%in dysmenorrhea group, 88.4%Korea China

Source Research objective(s)Method design Sample size Intervention Results Research location dysmenorrhea with obesity group.Cao X,Liu Z, Xu B [83]To look into the effects of acupuncture and ear acupuncture with moxibustion on obesity with pre-menstrual tension syndrome.131 women,aged 16-50.30-minute session,total 45 sessions.Effect rate: 87.8%.Reductions in body weight,BMI, body fat percentage.The younger, the more effective.China Gü?el F,Bahar B,Demirtas C, et al.[84]To examine the effects of acupuncture on weight loss.40 women.Unspecified age range.20-minute session,total 10 sessions.Acupoints: LI4,HT7, ST36, ST44,SP6.Reduction in body weight. Turkey Liu XG,Zhang J,Lu JL, et al. [85]Ren B,Liu Z, Xu B [86]Rerksuppa phol L[87]Zhang X,Tang X, Li W [88]To investigate the effects of laser acupuncture on obesity.To look into the effects of acupuncture and moxibustion on obese women with climacteric syndrome.To compare the effects of electro-acupunct ure and ear acupuncture and acupuncture alone on obesity.To examine the effects of electro-acupunct ure and medicinal moxibustion on obesity due to spleen and 28 female students,aged 19-25.151 obese women,aged 45-55.29 women,aged 21-60.58 women,aged 35-65.Divided into 1 placebo group, and 3 groups with different levels of laser (358, 478, and 597 J/cm2; powers:150, 200, and 250 MW; intensity:1194, 1592, and 1990 MW/cm2;irradiation time: 5 min/point, 25 min in total).Total 24 sessions.30-minute session,total 45 sessions.Randomly distributed to electro-acupuncture and ear acupuncture(n = 16), and ear acupuncture (n = 13)groups.30-minute session,unspecified total sessions.Randomly assigned to the acupuncture with medicinal moxibustion (n = 28,aged 35-62), and electro-acupuncture(n = 30, aged 37-65)groups.The laser groups receiving 358 and 597 J/cm2 showed significant reductions in body weight, BMI, body fat mass,waist girth, hip girth and waist-hip ratio after treatment compared with the placebo group. The percent reductions of body fat mass in the laser groups receiving 358 and 597 J/cm2 were 4.29% and 3.94%,respectively, and the corresponding values of body weight were 1.99% and 1.63%,respectively.Reductions in body weight,BMI, body fat percentage, and obesity index.Reduction in climacteric syndrome: 98.7%.Reduction in obesity: 85.5%.Higher reductions in body weight, BMI, waist circumference, hip circumference, waist-hip ratio,triceps skinfold thickness,subscapular thickness, mid arm circumference in electro-acupuncture and ear acupuncture group than in ear acupuncture group.92.9% in acupuncture with medicinal moxibustion group,and 70% in electro-acupuncture group.China China Thailand.China

Source Research objective(s)Method design Sample size Intervention Results Research location kidney yang deficiency.40-minute acupuncture with moxibustion per daily session, total 15 sessions.Shi W, Liu Z, Xu B[89]To investigate the effects of acupuncture and ear acupuncture on obese women with .102 obese women with .30-minute daily session, total 30 sessions.Effect rate: 95.1% on weight loss, 100% on menstrual pain.Reductions in weight, BMI,degree of obesity, body fat percentage, and menstrual pain.The younger, the more effective on weight loss.Effect rate after 10 sessions:81.4% on weight loss, 92.2% on menstrual pain.Effect rate after 20 sessions:92.2% on weight loss, 100% on menstrual pain.Effect rate after 30 sessions:97.1% on weight loss, 100% on menstrual pain.China Yang YD,Zhang YM [90]Abd KS,Kosery SM,Shamy FF,et al. [91]To test the effects of acupuncture and Chinese medicine on obesity.To investigate the effects of electro-acupunct ure on body fact composition.38 women,aged 16-51.20 obese postmenopa-usal women,aged 50-60.45-60 minutes session, total 15 sessions.30-minute session,total 24 sessions.Effect rate: 94.7%. China Reductions in BMI, waist-hip ratio, and body fat percentage. Egypt Gao X[92]Xu Y [93]Hsu CH,Wang CJ,Hwang KC, et al.[94]To compare the effects of acupuncture and Chinese medicine on perimenopausal obesity.To investigate the effects of acupuncture and ear acupuncture on obesity with dysmenorrhea.To examine the effects of ear acupuncture on obesity, and obesity-related hormone peptides.108 obese women,aged 40-55.808 obese women with dysmenorrh ea, aged 13-50.45 obese women,aged 16-65.Divided into the acupuncture (n =54), and Chinese medicine (n = 54)groups.30-minute session,total 30 sessions.Divided into the obesity (n = 407,aged 16-44), and obesity with dysmenorrhea (n =401, aged 13-50)groups.30-minute session,total 45 sessions.Randomly distributed to ear acupuncture (n =23), and sham ear acupuncture (n = 22)groups.Total 12 sessions.Effect rate of obesity: 96.1% in acupuncture, 69.4% in Chinese medicine.Effect rate of menopausal syndrome: 82.4% in acupuncture, 84.7% in Chinese medicine.Effect rate: 96.3% in obesity group, 89% in obesity with dysmenorrhea.Reduction in dysmenorrhea:89%.No significant reductions in body weight, BMI, waist circumference in both groups.A significant increase in ghrelin level and decrease in leptin level in ear acupuncture group but not in sham ear acupuncture group.China China Taiwan Cabioglu MT,To compare the effects of 55 women,aged 35-50.Allocated to the no treatment (n = 12),4.8% of weight loss in electro-acupuncture, and 2.5% Turkey

Note: BMI, Body mass index; TC, Total cholesteroal; TG, Triglycerides; LDL-C, Low density lipoprotein cholesterol;HDL-C, High density lipoprotein cholesterol

Thirty Sudanese women, aged 15-50 years old, who experienced 30-minute acupuncture sessions for 80 treatments, reduced their body weight, BMI, abdominal subcutaneous fat thickness, and prehepatic fat thickness;although an earlier study found no effects after using ear acupuncture in 45 women for 12 sessions [71, 94]. Laser acupuncture at 358 and 597 J/cm2for 24 sessions showed the highest efficacy towards improvements in body weight, BMI, body fat mass, waist girth, hip girth, and waist-hip ratio [85]. Rerksuppaphol looked into how to combine electro-acupuncture and ear acupuncture to manage excess fat accumulation, decreasing body weight,BMI, waist circumference, hip circumference, waist-hip ratio, triceps skinfold thickness, subscapular thickness,and middle arm circumference [87]. Moreover, many attempts at using other methods with acupuncture also substantiated the effects on obesity; for example, with massage, Chinese herbs, electro-acupuncture and moxibustion, and diet management [75, 88, 90, 95].Notwithstanding, each of these projects included a small number of individuals (less than 60).

While obesity with comorbidity is common,acupuncture is adopted to cope with these conditions,within which obstetrics and gynaecology are inseparable within various lifespan phases among women.

Hyperlipidaemia

Obesity-related hyperlipidaemia (high levels of cholesterol and triglycerides) harms people’s health.Adiposity is connected with hyperlipidaemia, a low level of high density lipoprotein cholesterol (HDL-C), and a high level of low density lipoprotein cholesterol (LDL-C),frequently linking to diabetes and hypertension [96-100].Pang and colleagues recruited 130 participants who were 18-54 years old to compare the effects of warming acupuncture and ear acupuncture on obesity with hyperlipidaemia [77]. The women were randomly and evenly allocated to these two groups. The warming acupuncture group underwent 45 sessions for 30-minute each time, showing an effect rate of 95.4%, compared with 84.6% in the ear acupuncture group. This efficacy encompassed reductions in body weight, BMI, degree of obesity, body fat percentage, decreases in serum total cholesteroal (TC,) triglycerides (TG), LDL-C, and an increase in HDL-C. This study was supported by another project with 126 women aged 17-62 [76].

Breast hyperplasia

Breast hyperplasia is connected with benign lesions or cancer [101]. Electro-acupuncture was applied to 67 obese women with breast hyperplasia, aged 16-58, who received 45 sessions for 30-minute each time [78]. 95.5%of the participants saw a reduction in body weight, BMI,circumferences of chest, waist, hip, thigh and waist-hip ratio. However, a control group was absent to detail a fuller picture of the outcomes.

Polycystic ovary syndrome

Obesity linked with polycystic ovary syndrome increases infertility rates [102]. One 6-month study compared the effectiveness of between acupuncture and acupuncture with metformin (medication) on 100 young obese women(22-38 years old) who suffered from polycystic ovary syndrome [74]. The participants were randomly distributed to acupuncture with metformin (n = 50) and metformin alone (n = 50) groups. They took the drug thrice a day. Each acupuncture session lasted 30 minutes.Both groups reported decreases in hormones, the size of cystic ovaries, body weight, BMI, and waist-hip ratios,while the mixed method group gained more significant improvements.

Pre-menstrual tension syndrome

Adiposity feasibly induces pre-menstrual tension syndrome (for instance, headaches, irritable feeling, and mood swings), through negative impacts on changes in hormones and neurochemicals [103]. A combination of acupuncture, ear acupuncture, and moxibustion was used for 131 women with pre-menstrual tension syndrome,ranging from 16-50 years old, who completed 45 sessions for 30-minute each [83]. The effect rate reached 87.8%, in which the participants observed reductions in body weight, BMI and body fat percentages and improvements in mood problems. Also, the younger women showed more effective results.

Table 2 Results of acupuncture for dysmenorrhea

Table 3 Results of the 102 participants

Dysmenorrhea

Dysmenorrhea (menstrual cramp) can occur among both underweight and overweight women [104]. Ren investigated how warming acupuncture and ear acupuncture can alleviate primary dysmenorrhea [82].Eighty-seven participants, including 44 normal weight women with dysmenorrhea and 43 obese women with dysmenorrhea, took 90 sessions for 30 minutes each.They highlighted the association of treatment outcomes and number of treatments (refer to Table 2)

Having undergone 30 body and ear acupuncture sessions for 30 minutes each, 95.1% of 102 participants achieved weight loss, and decreased BMI, body fat percentages, and degrees of obesity, together with 100%experiencing diminished menstrual pain [89]. They reported the relationship between sessions taken and effectiveness (Table 3), and depicted the result among the younger women, the better effect rate. These outcomes were also underpinned by another 808 women who were 13-50 years old [93].

Post-natal obesity

Postpartum weight retention may last one year after delivery and is associated with a higher possibility of obesity [105]. Laser acupuncture was applied to 32 postpartum women, who reported decreases in body weight, BMI, and body fat percentages [72]. Excessive weight gain in post-natal mothers may accompany lower breastfeeding rates, which increases the number of obese children, caused by the inverse correlation between breastfeeding and infant obesity [106-107]. Wang and colleagues led a comparison study to evaluate the effects of acupuncture and other complementary and alternative therapies on tackling post-natal obesity [72]. Thirty-eight post-natal informants (25-40 years old) were equally divided into two groups: one in which the participants received 30-minute acupuncture sessions, massage,cupping, diet control, and physical exercise, and another for diet and exercise only. The overall effect rate was shown to be 89.5% in the former group and 52.6% in the latter. However, such a small sample size results in a lack of sufficient data, especially without a control group.

Menopause

Menopause-based health problems are experienced across different stages of menopause due to a loss of estrogen, or to other hormonal changes [108]. Although most women have no apparent symptoms during their premenopausal period, some will encounter overeating, bloating, and irritability. Forty-six premenopausal women between 20 and 54 years old were randomly assigned to acupuncture(n = 23) and sham acupuncture (n = 23) groups,deactivating the parasympathetic function and increasing sympathetic activity [81]. Gao worked with 108 obese women who were in peri-menopause (aged 40-55) [92].After undergoing 30 sessions for 30-minute each of acupuncture, 96.1% experienced weight loss and 82.4%saw a decrease in menopausal syndrome. Another 91 women, aged 43-54, reported significant decrease in Kupperman menopausal index (an assessment tool for climacteric symptoms) and follicle-stimulating hormone[79]. They completed 36 warming acupuncture sessions,following which 88.4% delineated diminished body weight, BMI, and degrees of obesity, and 99.1% realised an abatement in climacteric syndrome. Congenial results were presented in a separate study with 151 individuals aged 25-55 who accepted a mixed treatment of acupuncture and moxibustion [86]. Electro-acupuncture was used in 20 post-menopausal women (50-60 years old),showing declines in BMI, waist-hip ratios, and body fat percentages after 30 treatments over 12 weeks [91].Again, further research with a larger sample population is necessary for richer evidence.

Depression

Research has demonstrated a direct correlation between being overweight and mood disorders; for instance,suffering from depression [109-110]. In contrast, little improvement was shown in obesity and depression for 24 participants [80]. Although this was an encouraging trial in Turkey, its small number of participants, no control group, and limited treatment sessions (n = 6) affected the outcomes.

Recommendations

Women with obesity suffer from not only adiposity-led illnesses but also obstetric and gynaecological diseases,for which the reviewed 25 studies illustrate positive signs for coping with these threats through acupuncture. This improves women’s health across different phases of their lifespan. However, enhancements in research design are essential to increase the reliability.

Even though there are nine randomised controlled trials,many of them have insufficient description of how the randomisation was processed, how acupuncture was applied, or the limitations of the research design. These details are necessary for replication, not only for clinical purposes but also scientific research, which help optimise the use of acupuncture in obesity and its related issues.

Out of the reviewed 25 studies, there is only one project which conducted follow-up, thus they all illustrate merely the short-term effects of acupuncture. This review proposes long-term research to substantiate acupuncture in the long-run and gain more in-depth investigation[111].

Twelve studies (48%) were carried out with a small sample size of less than 60 participants. Such a pitfall is unable to satisfy the requirements of convincing research.This review suggests that future projects be conducted with a larger number of participants to strengthen data reliability in the empirical research.

Combined treatments in the reviewed studies showed the efficacy of using acupuncture and other methods in overweight conditions or obesity; therefore, this review recommends an integrative approach. For example, in combination with physical activities, and food choices.Physical exercise plays a vital role in weight control by consuming energy, regulating food intake, and modifying sedentary behaviour [112]. It can also be conducive to better health-related qualify of life and accommodate even pregnant women under guidance [113]. In addition,healthy eating is a common cornerstone of weight management and general health [114-115].

Conclusion

This literature review delves into the usefulness of acupuncture, either alone or with other methods, in managing obesity, and treating related health problems and obstetric and gynaecological challenges, involving over 2,400 females from 13-65 years old in China, Egypt,Korea, Taiwan, Thailand, Turkey, Sudan, and USA. The reviewed 25 studies give encouraging indications; thus,this research suggests the adoption of acupuncture, by itself alone or with other therapeutic strategies, as an adjunct therapy to ameliorate women’s health.Nevertheless, there is room for improvements in future research for carrying out scientific projects.