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J Acupunct Meridian Stud 2014;--(-):--e--
Available online at www.sciencedirect.com
Journal of Acupuncture and Meridian Studies journal homepage: www.jams-kpi.com
- RESEARCH
ARTICLE
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Effect of Combined Manual Acupuncture and Massage on Body Weight and Body Mass Index Reduction in Obese and Overweight Women: A Randomized, Short-term Clinical Trial Junfeng He 1,2, Xing Zhang 1, Yating Qu 2, Huiyong Huang 2,*, Xia Liu 2, Jia Du 2, Shengtong Guo 2 1
Liuyang Hospital of Traditional Chinese Medicine, The Affiliated Hospital to Hunan University of Chinese Medicine, Liuyang City, Hunan, PR China 2 Institute of TCM Diagnostic, Hunan University of Chinese Medicine, Changsha, Hunan, PR China Available online - - -
Received: Apr 14, 2014 Revised: Aug 20, 2014 Accepted: Aug 22, 2014 KEYWORDS acupuncture; body mass index; massage; obesity; overweight
Abstract Obesity is one of the leading health risk factors worldwide and is associated with several other risk factors and health problems. Acupuncture is utilized to treat a variety of health problems, one of which is obesity. Fifty-six obese women with body mass index (BMI) 25 kg/m2 were recruited for this trial and were randomly divided into two groups, one with combined manual acupuncture and massage therapy (MAMT), and the other with only manual acupuncture therapy (MAT). In addition, 40 overweight women with BMI 23e25 kg/ m2 were randomly divided into two groups, one with MAMT and the other with MAT. Therapy was carried out once per day for 21 days, and the body weights and the BMIs were recorded every day. The results showed that both MAMT and MAT could reduce body weight and BMI significantly, compared with the pretreatment values, for all the participants (p < 0.001); however, the differences in body weight and BMI reductions between preand posttreatment for the MAMT and the MAT groups were not statistically significant. The optimal periods for reductions in both body weight and in BMI were the first 4 days. Accounting for the economic strategy (time and money) in alternative therapy, MAT alone may present a reasonable option in the treatment of overweight and obesity in adults.
* Corresponding author. Institute of TCM Diagnostic, Hunan University of Chinese Medicine, Number 1 Xiangzui Road, Hanpu Science and Education District, Changsha 410208, Hunan Province, PR China. E-mail: [email protected] (H. Huang). pISSN 2005-2901 eISSN 2093-8152 http://dx.doi.org/10.1016/j.jams.2014.08.001 Copyright ª 2014, International Pharmacopuncture Institute. Please cite this article in press as: He J, et al., Effect of Combined Manual Acupuncture and Massage on Body Weight and Body Mass Index Reduction in Obese and Overweight Women: A Randomized, Short-term Clinical Trial, Journal of Acupuncture and Meridian Studies (2014), http://dx.doi.org/10.1016/j.jams.2014.08.001
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1. Introduction The prevalence of obesity is rapidly increasing worldwide, even in developing countries. Obesity and overweight are associated with many serious conditions, including type 2 diabetes, hypertension, and coronary heart disease [1]. Current conventional therapeutic strategies for treating obesity (i.e., diet, physical exercise, drugs, and bariatric surgery) cannot achieve adequate weight control in all patients. As one of the oldest healing practices in the world [2], acupuncture is utilized to treat a variety of health problem, one of which is obesity [3]. It exerts its effect through the insertion of thin metallic needles at specific points on the body that can be manipulated manually or by electrical stimulation. Massage could dredge Meridian Qi and promote blood circulation. Some acupuncturists feel that combined acupuncture and massage therapy might have an optimal effect in controlling body weight (BW), especially for obese patients. Some research [4,5] suggests that acupuncture intervention (in different forms) has beneficial effects in treating obesity, but in that research, the BW and body mass index (BMI) evaluation simply involved pre- and posttest comparisons; dynamic observations are lacking. This research was designed to answer three questions. First, is combined manual acupuncture and massage therapy (MAMT) more beneficial than manual acupuncture therapy (MAT) alone for treating obesity in woman? Second, are MAMT and MAT also good for treating overweight woman? Third, when is the optimal time for BW and BMI reductions during MAMT and MAT?
2. Materials and methods This study recruited 96 women who visited the outpatient acupuncture clinic at Liuyang Hospital of Traditional Chinese Medicine, Hunan, P.R. China between June 2012 and November 2013. Fifty-six participants with BMI 25 kg/m2 were randomly divided into two groups by using a random number generator: one with MAMT (obesity þ MAMT) and the other with MAT (obesity þ MAT). Forty overweight participants with BMI 23e25 kg/m2 were also randomly divided into two groups: one with MAMT (overweight þ MAMT) and the other with MAT (overweight þ MAT). Exclusion criteria for all participants included diabetes, pregnancy, hypertension, treatment with antidepressants, and use of weight loss drugs. All women were told to maintain their usual diet for the total duration of the study. None were engaged in physical training programs or calorie restriction protocols. Investigations were approved by the Ethics Committee of Liuyang Hospital of Traditional Chinese Medicine, and all participants gave written informed consent.
2.1. MAT protocol According to Traditional Chinese Medicine, ST25 (Tianshu), ST21 (Liangmen), SP15 (Daheng), ST36 (Zusanli), SP6 (Sanyinjiao), LI11 (Quchi), SJ6 (Zhigou) bilaterally, RN12 (Zhongwan), and RN06 (Qihai) were chosen as the acupoints to be used for the therapy. After standard disinfection of the skin, disposable stainless-steel needles (25-mm long, 0.25 mm in diameter, Kingli, Lianghong Road, Houzhai Town,
J. He et al. Jiangsu, China) were applied through the skin to a depth of 5e10 mm. The stimulation was manual, and the response sought was de qi. The needle remained in the acupoint for 30 minutes with interval manipulations. The treatment was done once per day for 21 days.
2.2. MAMT protocol At the end of manual acupuncture, following a 5-minute break, participants received massage. The Stomach Meridian of FooteYangming, the Ren Meridian, and the Dai Meridian in the abdomen were chosen. After the participants’ abdominal skin and the acupuncturist’s hands had been cleaned, the acupuncturist used the thenar eminence to rub the above meridians and acupressure to manipulate the above abdominal acupoints with moderate pressure for 25 minutes.
2.3. Outcome measures and data analysis Participants’ BW and BMI were recorded every day until the end of the trial, and daily changes in BW and BMI were calculated. SPSS software (version 13.0; SPSS Inc., Chicago, IL, USA) was used to analyze the data, and paired t tests were employed to examine differences. All p values were two-tailed, and the a level of significance was set at 0.05. For all parameters, the averages and the standard deviations were analyzed for significance by using the Student t test.
3. Results All participants completed the therapy program. In both the MAT and the MAMT groups, the BW and the BMI for the obese women decreased quickly during the first 4 days. However, the differences in the BW (p Z 0.629) and the BMI (p Z 0.525) reductions between the two groups was not statistically significant (Figs. 1 and 2). As with the obese woman, for overweight women in both the MAT and the MAMT groups, the body weight and the BMI decreased quickly during the first 4 days. However, the differences in the BW (p Z 0.266) and BMI (p Z 0.363) reductions between the two groups was not statistically significant (Figs. 1 and 2). At the end of trial, the posttreatment BW and BMI were compared with the pretreatment BW and BMI, respectively. In the obesity þ MAT group, for both BW and BMI, a very significant difference existed between pre- and posttreatment (p < 0.0001). Significant differences in both BW and BMI between pre- and posttreatment were also noted for the obesity þ MAMT, the overweight þ MAT, and the overweight þ MAMT groups, respectively (p < 0.0001). However, the differences in both body weight and BMI between pre- and posttreatment for the obesity þ MAT and the obesity þ MAMT groups were not statistically significant (p Z 0.143 and p Z 0.135, respectively). The same was true for the overweight þ MAT and the overweight þ MAMT groups (p Z 0.135 and p Z 0.195, respectively; Table 1).
4. Discussion BMI provides the most useful and practical population-level indicator of overweight and obesity in adults. In the graded
Please cite this article in press as: He J, et al., Effect of Combined Manual Acupuncture and Massage on Body Weight and Body Mass Index Reduction in Obese and Overweight Women: A Randomized, Short-term Clinical Trial, Journal of Acupuncture and Meridian Studies (2014), http://dx.doi.org/10.1016/j.jams.2014.08.001
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Acupuncture and massage for BMI reduction
Figure 1 Changes in daily body weight of the participants (mean standard error of the mean). MAMT Z combined manual acupuncture and massage therapy; MAT Z manual acupuncture therapy.
classification system developed by the World Health Organization, a BMI of 30 kg/m2 or above denotes obesity, and a BMI of 25 kg/m2 or above denotes overweight. Worldwide obesity has nearly doubled since 1980. In 2008, more than 1.4 billion adults, aged 20 years, were overweight. Of those, over 200 million men and nearly 300 million women were obese [6]. For Asians, the cut-offs for overweight (23.0 kg/m2) and obesity (25.0 kg/m2) are lower than the World Health Organization criteria [7]. These BMI thresholds differ from those determined for Caucasians because, compared with Caucasians, Asians present more comorbidities and a greater fat mass at lower BMI values [8,9]. Therefore, in this study, we chose the criteria recommended for Asians. There are many alternative treatments for obesity management, one of which is acupuncture. Although the mechanism of acupuncture for treating obesity is still unclear, research shows that the mechanism involves: a suppression of appetite [10]; regulation of obesity-related peptides (increases in cocaine and amphetamine-regulated transcript peptide, and decreases in ghrelin and leptin) [11e13] and fat metabolism (decreases in total cholesterol,
Figure 2 Changes in daily body mass index (BMI: kg/m2) of the participants (mean standard error of the mean). MAMT Z combined manual acupuncture and massage therapy; MAT Z manual acupuncture therapy.
3 triglycerides, low-density lipoprotein, lipoprotein A, and apolipoprotein B levels) [14,15]; increases in insulin and Cpeptide levels and, in cases of obesity, decreases in glucose levels [4]. Studies have reported on the beneficial effects of acupuncture for obesity control [5,10]. In one study, 16 volunteers with primary obesity (BMI 25 kg/m2) were recruited; the volunteers were given no instructions, and no attempts were made to control their diets. Each participant received acupoint nerve stimulation at ST21 (Liangmen), ST25 (Tianshu), ST28 (Shuidao), ST34 (Liangqiu), and SP4 (Gongsun), distributed mainly in the abdominal area, three times per week for 12 weeks. The BW decreased steadily during the observation period, with a net decrease of 2.06 0.31 kg at the end of 12 weeks of treatment, corresponding to a decrease of 2.78 0.4% of the original BW (p < 0.01) [10]. Another investigation reported that without diet or exercise program, the acupuncture group, which received two sessions of 20 minutes every week for a total of 10 sessions with acupuncture at LI4 (Hegu), HT7 (Shenmen), ST36 (Zusanli), ST44 (Neiting), and SP6 (Sanyinjiao) bilaterally, showed an average 2.9-kg weight loss after 5 weeks [5]. Similarly, our study showed that short-term (21 days) acupuncture therapy reduced BW by 2.91 kg and 2.45 kg, on average, in obese and overweight women, respectively. Massage, also known as Tuina, is widely used in China for obesity treatment. Massage is claimed to have no pain, which is a unique advantage for obese children and needleafraid adults. In one study in which massage was applied on abdominal meridians and acupressure at RN13 (Shangwan), RN12 (Zhongwan), RN8 (Shenque), RN6 (Qihai), RN4 (Guanyuan), and ST25 (Tianshu) once per day for 10 weeks, 47 of the 50 obese patients experienced a satisfactory reduction in BMI compared with the 10-mg daily sibutramine-tablet oral-administration groups, the sham massage group, and the blank group [16]. According to another report on 65 obese adults who underwent massage on the abdominal and the reflex zones in the feet once per day for 8 weeks, the BW dropped from 68.54 10.45 kg to 57.66 8.63 kg while the BMI dropped from 26.75 2.31 kg/m2 to 24.39 2.15 kg/m2, but there were no significant differences between pre- and posttest results (p < 0.05) for both BW and BMI [17]. Underlying acupuncture’s efficacy, the mechanism of massage in treating obesity may involve degradation or catabolism of adipose [16], a promotion of intestinal peristalsis [18], and a reduction in the excitability of the parasympathetic nerve [19]. The double-blind placebo-controlled clinical trial is recognized as the gold standard for showing whether an intervention has a specific effect over a placebo or a control. However, a double-blind design for an acupuncture study is difficult because the acupuncturist has to be aware of the method applied [20]. Therefore, in this study, we could only evaluate the effects of acupuncture and of combined acupuncture and massage on obesity and overweight in a randomized trial. In general, combined methods are always thought to be more effective for treating obesity. According to research involving a combination group receiving acupuncture at GV20 (Baihui), CV12 (Zhongwan), ST36 (Zusanli), ST21 (Liangmen), ST25 (Tianshu), LIV3 (Taichong), LIV13 (Zhangmen), P6 (Neiguan), H7 (Shenmen), and auriculotherapy-55 (Shenmen) and 87
Please cite this article in press as: He J, et al., Effect of Combined Manual Acupuncture and Massage on Body Weight and Body Mass Index Reduction in Obese and Overweight Women: A Randomized, Short-term Clinical Trial, Journal of Acupuncture and Meridian Studies (2014), http://dx.doi.org/10.1016/j.jams.2014.08.001
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J. He et al. Table 1
Body weight and body mass index changes in participants during the trial. Body mass index (kg/m2)
Body weight (kg) Pretreatment Obesity þ MAT Obesity þ MAMT Overweight þ MAT Overweight þ MAMT
69.68 63.40 59.22 57.32
0.98 0.93 1.11 0.64
Posttreatment 66.77 61.00 56.78 55.44
0.96* 0.83* 1.18* 0.75*
Difference 2.91 2.41 2.44 1.88
Pretreatment y
0.21 0.27 0.21x 0.25
27.64 25.87 23.24 22.74
0.29 0.21 0.20 0.22
Posttreatment 26.44 24.88 22.27 21.98
0.29* 0.21* 0.22* 0.26*
Difference 1.20 0.99 0.97 0.76
0.09z 0.10 0.09k 0.10
*p < 0.0001 compared with pretreatment,. y p Z 0.143, zp Z 0.135 compared with obesity þ MAMT. x p Z 0.135, kp Z 0.195 compared with overweight þ MAMT. MAMT Z combined manual acupuncture and massage therapy; MAT Z manual acupuncture therapy.
(Stomach), and a low-calorie slimming diet for a 6-week period, the mean drop in the BW, as well as the BMI, was significantly higher in the combination group (12.81 2.85 kg and 5.03 1.08 kg/m2, respectively) than in the low-calorie diet alone group (8.41 2.02 kg and 3.28 0.78 kg/m2, respectively; p < 0.01) [21]. In another randomized clinical trial in which obese patients were divided into diet þ exercise þ acupuncture, diet þ exercise, and control groups, significant decreases (p < 0.05) in BMI and fat mass were observed in both intervention groups compared with the control group, but the differences between the intervention groups regarding lean body mass were not significant [22]. Similarly, our study showed that both BW and BMI were reduced in all participants after the 21-day intervention, but there were no significant differences between the acupuncture with massage group and the acupuncture alone group for either obese or overweight women. Perhaps, the short-term treatment or massage therapy protocol may not have been optimal, which could have resulted in the similar efficacies of the two interventions. Losing weight is a challenge in modern times, and we are still searching for the most efficient method. Choosing the right method is crucial for the patient [5]. In our study, both combined acupuncture and massage, and acupuncture alone reduced BW and BMI after 21 days of treatment, and the effect was prominent in the first 4 days. Given the current results and accounting for the economic strategy (time and money) in alternative therapy, MAT alone may present a reasonable option in the treatment of overweight and obesity in adults. However, the effects of long-term treatment and follow-up treatment should be assessed in future studies.
Conflicts of interest All contributing authors declare no conflicts of interest.
Acknowledgments This work was supported by the National Natural Science Foundation of China (No. 81373717 and No. 81373551), by the Fund of Open Innovation Platform in Hunan College (No. 12K084) and by the Scientific Research Fund of Hunan Provincial Science and Technology Department (No. 2012FJ4285).
References [1] Pi-Sunyer FX. The obesity epidemic: pathophysiology and consequences of obesity. Obes Res. 2002 Dec;10(Suppl. 2): 97Se104S. [2] NIH Consensus Conference Acupuncture. JAMA. 1998;280: 1518e1524. [3] Lacey JM, Tershakovec AM, Foster GD. Acupuncture for the treatment of obesity: a review of evidence. Int J Obes Relat Metab Disord. 2003;27:419e427. [4] Cabioǧlu MT, Ergene N. Changes in levels of serum insulin, Cpeptide and glucose after electroacupuncture and diet therapy in obese women. Am J Chin Med. 2006;34:367e376. [5] Gu cel F, Bahar B, Demirtas C, Mit S, C ¸ evik C. Influence of ¨¸ acupuncture on leptin, ghrelin, insulin and cholecystokinin in obese women: a randomised, sham-controlled preliminary trial. Acupunct Med. 2012;30:203e207. [6] World Health Organization. Obesity and overweight. Available at: http://www.who.int/mediacentre/factsheets/fs311/en/. [Date accessed: Updated August 2014]. [7] World Health Organization, Western Pacific Region, The international association for the study of obesity and the international obesity task force. The Asia-Pacific Perspective: Redefining Obesity and its Treatment. Sydney, Australia: Health Communications Australia Pty Limited; 2000. [8] Chang CJ, Wu CH, Chang CS, Yao WJ, Yang YC, Wu JS, et al. Low body mass index but high percent body fat in Taiwanese subjects: implications of obesity cutoffs. Int J Obes Relat Metab Disord. 2003;27:253e259. [9] Pan WH, Flegal KM, Chang HY, Yeh WT, Yeh CJ, Lee WC. Body mass index and obesity-related metabolic disorders in Taiwanese and US whites and blacks: implications for definitions of overweight and obesity for Asians. Am J Clin Nutr. 2004;79:31e39. [10] Wang F, Tian DR, Han JS. Electroacupuncture in the treatment of obesity. Neurochem Res. 2008;33:2023e2027. [11] Tian DR, Li XD, Wang F, Niu DB, He QH, Li YS , et al. Upregulation of the expression of cocaine and amphetamineregulated transcript peptide by electroacupuncture in the arcuate nucleus of diet-induced obese rats. Neurosci Lett. 2005;383:17e21. [12] Tian N, Wang F, Tian DR, Zou Y, Wang SW, Guan LL, et al. Electroacupuncture suppresses expression of gastric ghrelin and hypothalamic NPY in chronic food restricted rats. Peptides. 2006;27:2313e2320. [13] Kim SK, Lee G, Shin M, Han JB, Moon HJ, Park JH, et al. The association of serum leptin with the reduction of food intake and body weight during electroacupuncture in rats. Pharmacol Biochem Behav. 2006;83:145e149. [14] Cabioǧlu MT, Gu ¨ndogan N, Ergene N. The efficacy of electroacupuncture therapy for weight loss changes plasma
Please cite this article in press as: He J, et al., Effect of Combined Manual Acupuncture and Massage on Body Weight and Body Mass Index Reduction in Obese and Overweight Women: A Randomized, Short-term Clinical Trial, Journal of Acupuncture and Meridian Studies (2014), http://dx.doi.org/10.1016/j.jams.2014.08.001
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[15]
[16]
[17]
[18]
lipoprotein A, apolipoprotein A and apolipoprotein B levels in obese women. Am J Chin Med. 2008;36:1029e1039. Cabioǧlu MT, Ergene N. Electroacupuncture therapy for weight loss reduces serum total cholesterol, triglycerides, and LDL cholesterol levels in obese women. Am J Chin Med. 2005; 33:525e533. Guo X, Shao XN, Wei GW, Chen MR, Liu JW. Effect of meridian tuina on serum insulin and triglyceride of 50 simple obesity patients. J Tradit Chin Med. 2008;49:906e908 [In Chinese]. Shan G. Combined massage and pelma reflex zones to treat 65 cases of obesity. Trad Chin Med Res. 2011;24:73e75 [In Chinese]. Wei FQ, Zhao X, Wang Y. Treatment of 30 cases of simple obesity with combined manual acupuncture and massage. Chin Acupun Moxibust. 2004;(Suppl.):86e87 [In Chinese].
5 [19] Gao X, Lv YN. Progress on research of the effect mechanism of acupuncture and massage in weight loss. Chin J New Clin Med. 2010;7:694e696 [In Chinese]. [20] Hsu CH, Hwang KC, Chao CL, Lin JG, Kao ST, Chou P. Effects of electroacupuncture in reducing weight and waist circumference in obese women: a randomized crossover trial. Int J Obes. 2005 Nov;29(11):1379e1384. [21] Wozniak P, Oszukowski P, Stachowiak G, Szyłło K. The effectiveness of low-calorie diet or diet with acupuncture treatment in obese peri- and postmenopausal women. Ginekol Pol. 2003 Feb;74(2):102e107 [in Polish]. [22] Nourshahi M, Ahmadizad S, Nikbakht H, Heidarnia MA, Ernst E. The effects of triple therapy (acupuncture, diet and exercise) on body weight: a randomized, clinical trial. Int J Obes (Lond). 2009 May;33(5):583e587.
Please cite this article in press as: He J, et al., Effect of Combined Manual Acupuncture and Massage on Body Weight and Body Mass Index Reduction in Obese and Overweight Women: A Randomized, Short-term Clinical Trial, Journal of Acupuncture and Meridian Studies (2014), http://dx.doi.org/10.1016/j.jams.2014.08.001
MODEL
J Acupunct Meridian Stud 2014;--(-):--e--
Available online at www.sciencedirect.com
Journal of Acupuncture and Meridian Studies journal homepage: www.jams-kpi.com
- RESEARCH
ARTICLE
-
Effect of Combined Manual Acupuncture and Massage on Body Weight and Body Mass Index Reduction in Obese and Overweight Women: A Randomized, Short-term Clinical Trial Junfeng He 1,2, Xing Zhang 1, Yating Qu 2, Huiyong Huang 2,*, Xia Liu 2, Jia Du 2, Shengtong Guo 2 1
Liuyang Hospital of Traditional Chinese Medicine, The Affiliated Hospital to Hunan University of Chinese Medicine, Liuyang City, Hunan, PR China 2 Institute of TCM Diagnostic, Hunan University of Chinese Medicine, Changsha, Hunan, PR China Available online - - -
Received: Apr 14, 2014 Revised: Aug 20, 2014 Accepted: Aug 22, 2014 KEYWORDS acupuncture; body mass index; massage; obesity; overweight
Abstract Obesity is one of the leading health risk factors worldwide and is associated with several other risk factors and health problems. Acupuncture is utilized to treat a variety of health problems, one of which is obesity. Fifty-six obese women with body mass index (BMI) 25 kg/m2 were recruited for this trial and were randomly divided into two groups, one with combined manual acupuncture and massage therapy (MAMT), and the other with only manual acupuncture therapy (MAT). In addition, 40 overweight women with BMI 23e25 kg/ m2 were randomly divided into two groups, one with MAMT and the other with MAT. Therapy was carried out once per day for 21 days, and the body weights and the BMIs were recorded every day. The results showed that both MAMT and MAT could reduce body weight and BMI significantly, compared with the pretreatment values, for all the participants (p < 0.001); however, the differences in body weight and BMI reductions between preand posttreatment for the MAMT and the MAT groups were not statistically significant. The optimal periods for reductions in both body weight and in BMI were the first 4 days. Accounting for the economic strategy (time and money) in alternative therapy, MAT alone may present a reasonable option in the treatment of overweight and obesity in adults.
* Corresponding author. Institute of TCM Diagnostic, Hunan University of Chinese Medicine, Number 1 Xiangzui Road, Hanpu Science and Education District, Changsha 410208, Hunan Province, PR China. E-mail: [email protected] (H. Huang). pISSN 2005-2901 eISSN 2093-8152 http://dx.doi.org/10.1016/j.jams.2014.08.001 Copyright ª 2014, International Pharmacopuncture Institute. Please cite this article in press as: He J, et al., Effect of Combined Manual Acupuncture and Massage on Body Weight and Body Mass Index Reduction in Obese and Overweight Women: A Randomized, Short-term Clinical Trial, Journal of Acupuncture and Meridian Studies (2014), http://dx.doi.org/10.1016/j.jams.2014.08.001
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1. Introduction The prevalence of obesity is rapidly increasing worldwide, even in developing countries. Obesity and overweight are associated with many serious conditions, including type 2 diabetes, hypertension, and coronary heart disease [1]. Current conventional therapeutic strategies for treating obesity (i.e., diet, physical exercise, drugs, and bariatric surgery) cannot achieve adequate weight control in all patients. As one of the oldest healing practices in the world [2], acupuncture is utilized to treat a variety of health problem, one of which is obesity [3]. It exerts its effect through the insertion of thin metallic needles at specific points on the body that can be manipulated manually or by electrical stimulation. Massage could dredge Meridian Qi and promote blood circulation. Some acupuncturists feel that combined acupuncture and massage therapy might have an optimal effect in controlling body weight (BW), especially for obese patients. Some research [4,5] suggests that acupuncture intervention (in different forms) has beneficial effects in treating obesity, but in that research, the BW and body mass index (BMI) evaluation simply involved pre- and posttest comparisons; dynamic observations are lacking. This research was designed to answer three questions. First, is combined manual acupuncture and massage therapy (MAMT) more beneficial than manual acupuncture therapy (MAT) alone for treating obesity in woman? Second, are MAMT and MAT also good for treating overweight woman? Third, when is the optimal time for BW and BMI reductions during MAMT and MAT?
2. Materials and methods This study recruited 96 women who visited the outpatient acupuncture clinic at Liuyang Hospital of Traditional Chinese Medicine, Hunan, P.R. China between June 2012 and November 2013. Fifty-six participants with BMI 25 kg/m2 were randomly divided into two groups by using a random number generator: one with MAMT (obesity þ MAMT) and the other with MAT (obesity þ MAT). Forty overweight participants with BMI 23e25 kg/m2 were also randomly divided into two groups: one with MAMT (overweight þ MAMT) and the other with MAT (overweight þ MAT). Exclusion criteria for all participants included diabetes, pregnancy, hypertension, treatment with antidepressants, and use of weight loss drugs. All women were told to maintain their usual diet for the total duration of the study. None were engaged in physical training programs or calorie restriction protocols. Investigations were approved by the Ethics Committee of Liuyang Hospital of Traditional Chinese Medicine, and all participants gave written informed consent.
2.1. MAT protocol According to Traditional Chinese Medicine, ST25 (Tianshu), ST21 (Liangmen), SP15 (Daheng), ST36 (Zusanli), SP6 (Sanyinjiao), LI11 (Quchi), SJ6 (Zhigou) bilaterally, RN12 (Zhongwan), and RN06 (Qihai) were chosen as the acupoints to be used for the therapy. After standard disinfection of the skin, disposable stainless-steel needles (25-mm long, 0.25 mm in diameter, Kingli, Lianghong Road, Houzhai Town,
J. He et al. Jiangsu, China) were applied through the skin to a depth of 5e10 mm. The stimulation was manual, and the response sought was de qi. The needle remained in the acupoint for 30 minutes with interval manipulations. The treatment was done once per day for 21 days.
2.2. MAMT protocol At the end of manual acupuncture, following a 5-minute break, participants received massage. The Stomach Meridian of FooteYangming, the Ren Meridian, and the Dai Meridian in the abdomen were chosen. After the participants’ abdominal skin and the acupuncturist’s hands had been cleaned, the acupuncturist used the thenar eminence to rub the above meridians and acupressure to manipulate the above abdominal acupoints with moderate pressure for 25 minutes.
2.3. Outcome measures and data analysis Participants’ BW and BMI were recorded every day until the end of the trial, and daily changes in BW and BMI were calculated. SPSS software (version 13.0; SPSS Inc., Chicago, IL, USA) was used to analyze the data, and paired t tests were employed to examine differences. All p values were two-tailed, and the a level of significance was set at 0.05. For all parameters, the averages and the standard deviations were analyzed for significance by using the Student t test.
3. Results All participants completed the therapy program. In both the MAT and the MAMT groups, the BW and the BMI for the obese women decreased quickly during the first 4 days. However, the differences in the BW (p Z 0.629) and the BMI (p Z 0.525) reductions between the two groups was not statistically significant (Figs. 1 and 2). As with the obese woman, for overweight women in both the MAT and the MAMT groups, the body weight and the BMI decreased quickly during the first 4 days. However, the differences in the BW (p Z 0.266) and BMI (p Z 0.363) reductions between the two groups was not statistically significant (Figs. 1 and 2). At the end of trial, the posttreatment BW and BMI were compared with the pretreatment BW and BMI, respectively. In the obesity þ MAT group, for both BW and BMI, a very significant difference existed between pre- and posttreatment (p < 0.0001). Significant differences in both BW and BMI between pre- and posttreatment were also noted for the obesity þ MAMT, the overweight þ MAT, and the overweight þ MAMT groups, respectively (p < 0.0001). However, the differences in both body weight and BMI between pre- and posttreatment for the obesity þ MAT and the obesity þ MAMT groups were not statistically significant (p Z 0.143 and p Z 0.135, respectively). The same was true for the overweight þ MAT and the overweight þ MAMT groups (p Z 0.135 and p Z 0.195, respectively; Table 1).
4. Discussion BMI provides the most useful and practical population-level indicator of overweight and obesity in adults. In the graded
Please cite this article in press as: He J, et al., Effect of Combined Manual Acupuncture and Massage on Body Weight and Body Mass Index Reduction in Obese and Overweight Women: A Randomized, Short-term Clinical Trial, Journal of Acupuncture and Meridian Studies (2014), http://dx.doi.org/10.1016/j.jams.2014.08.001
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Acupuncture and massage for BMI reduction
Figure 1 Changes in daily body weight of the participants (mean standard error of the mean). MAMT Z combined manual acupuncture and massage therapy; MAT Z manual acupuncture therapy.
classification system developed by the World Health Organization, a BMI of 30 kg/m2 or above denotes obesity, and a BMI of 25 kg/m2 or above denotes overweight. Worldwide obesity has nearly doubled since 1980. In 2008, more than 1.4 billion adults, aged 20 years, were overweight. Of those, over 200 million men and nearly 300 million women were obese [6]. For Asians, the cut-offs for overweight (23.0 kg/m2) and obesity (25.0 kg/m2) are lower than the World Health Organization criteria [7]. These BMI thresholds differ from those determined for Caucasians because, compared with Caucasians, Asians present more comorbidities and a greater fat mass at lower BMI values [8,9]. Therefore, in this study, we chose the criteria recommended for Asians. There are many alternative treatments for obesity management, one of which is acupuncture. Although the mechanism of acupuncture for treating obesity is still unclear, research shows that the mechanism involves: a suppression of appetite [10]; regulation of obesity-related peptides (increases in cocaine and amphetamine-regulated transcript peptide, and decreases in ghrelin and leptin) [11e13] and fat metabolism (decreases in total cholesterol,
Figure 2 Changes in daily body mass index (BMI: kg/m2) of the participants (mean standard error of the mean). MAMT Z combined manual acupuncture and massage therapy; MAT Z manual acupuncture therapy.
3 triglycerides, low-density lipoprotein, lipoprotein A, and apolipoprotein B levels) [14,15]; increases in insulin and Cpeptide levels and, in cases of obesity, decreases in glucose levels [4]. Studies have reported on the beneficial effects of acupuncture for obesity control [5,10]. In one study, 16 volunteers with primary obesity (BMI 25 kg/m2) were recruited; the volunteers were given no instructions, and no attempts were made to control their diets. Each participant received acupoint nerve stimulation at ST21 (Liangmen), ST25 (Tianshu), ST28 (Shuidao), ST34 (Liangqiu), and SP4 (Gongsun), distributed mainly in the abdominal area, three times per week for 12 weeks. The BW decreased steadily during the observation period, with a net decrease of 2.06 0.31 kg at the end of 12 weeks of treatment, corresponding to a decrease of 2.78 0.4% of the original BW (p < 0.01) [10]. Another investigation reported that without diet or exercise program, the acupuncture group, which received two sessions of 20 minutes every week for a total of 10 sessions with acupuncture at LI4 (Hegu), HT7 (Shenmen), ST36 (Zusanli), ST44 (Neiting), and SP6 (Sanyinjiao) bilaterally, showed an average 2.9-kg weight loss after 5 weeks [5]. Similarly, our study showed that short-term (21 days) acupuncture therapy reduced BW by 2.91 kg and 2.45 kg, on average, in obese and overweight women, respectively. Massage, also known as Tuina, is widely used in China for obesity treatment. Massage is claimed to have no pain, which is a unique advantage for obese children and needleafraid adults. In one study in which massage was applied on abdominal meridians and acupressure at RN13 (Shangwan), RN12 (Zhongwan), RN8 (Shenque), RN6 (Qihai), RN4 (Guanyuan), and ST25 (Tianshu) once per day for 10 weeks, 47 of the 50 obese patients experienced a satisfactory reduction in BMI compared with the 10-mg daily sibutramine-tablet oral-administration groups, the sham massage group, and the blank group [16]. According to another report on 65 obese adults who underwent massage on the abdominal and the reflex zones in the feet once per day for 8 weeks, the BW dropped from 68.54 10.45 kg to 57.66 8.63 kg while the BMI dropped from 26.75 2.31 kg/m2 to 24.39 2.15 kg/m2, but there were no significant differences between pre- and posttest results (p < 0.05) for both BW and BMI [17]. Underlying acupuncture’s efficacy, the mechanism of massage in treating obesity may involve degradation or catabolism of adipose [16], a promotion of intestinal peristalsis [18], and a reduction in the excitability of the parasympathetic nerve [19]. The double-blind placebo-controlled clinical trial is recognized as the gold standard for showing whether an intervention has a specific effect over a placebo or a control. However, a double-blind design for an acupuncture study is difficult because the acupuncturist has to be aware of the method applied [20]. Therefore, in this study, we could only evaluate the effects of acupuncture and of combined acupuncture and massage on obesity and overweight in a randomized trial. In general, combined methods are always thought to be more effective for treating obesity. According to research involving a combination group receiving acupuncture at GV20 (Baihui), CV12 (Zhongwan), ST36 (Zusanli), ST21 (Liangmen), ST25 (Tianshu), LIV3 (Taichong), LIV13 (Zhangmen), P6 (Neiguan), H7 (Shenmen), and auriculotherapy-55 (Shenmen) and 87
Please cite this article in press as: He J, et al., Effect of Combined Manual Acupuncture and Massage on Body Weight and Body Mass Index Reduction in Obese and Overweight Women: A Randomized, Short-term Clinical Trial, Journal of Acupuncture and Meridian Studies (2014), http://dx.doi.org/10.1016/j.jams.2014.08.001
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J. He et al. Table 1
Body weight and body mass index changes in participants during the trial. Body mass index (kg/m2)
Body weight (kg) Pretreatment Obesity þ MAT Obesity þ MAMT Overweight þ MAT Overweight þ MAMT
69.68 63.40 59.22 57.32
0.98 0.93 1.11 0.64
Posttreatment 66.77 61.00 56.78 55.44
0.96* 0.83* 1.18* 0.75*
Difference 2.91 2.41 2.44 1.88
Pretreatment y
0.21 0.27 0.21x 0.25
27.64 25.87 23.24 22.74
0.29 0.21 0.20 0.22
Posttreatment 26.44 24.88 22.27 21.98
0.29* 0.21* 0.22* 0.26*
Difference 1.20 0.99 0.97 0.76
0.09z 0.10 0.09k 0.10
*p < 0.0001 compared with pretreatment,. y p Z 0.143, zp Z 0.135 compared with obesity þ MAMT. x p Z 0.135, kp Z 0.195 compared with overweight þ MAMT. MAMT Z combined manual acupuncture and massage therapy; MAT Z manual acupuncture therapy.
(Stomach), and a low-calorie slimming diet for a 6-week period, the mean drop in the BW, as well as the BMI, was significantly higher in the combination group (12.81 2.85 kg and 5.03 1.08 kg/m2, respectively) than in the low-calorie diet alone group (8.41 2.02 kg and 3.28 0.78 kg/m2, respectively; p < 0.01) [21]. In another randomized clinical trial in which obese patients were divided into diet þ exercise þ acupuncture, diet þ exercise, and control groups, significant decreases (p < 0.05) in BMI and fat mass were observed in both intervention groups compared with the control group, but the differences between the intervention groups regarding lean body mass were not significant [22]. Similarly, our study showed that both BW and BMI were reduced in all participants after the 21-day intervention, but there were no significant differences between the acupuncture with massage group and the acupuncture alone group for either obese or overweight women. Perhaps, the short-term treatment or massage therapy protocol may not have been optimal, which could have resulted in the similar efficacies of the two interventions. Losing weight is a challenge in modern times, and we are still searching for the most efficient method. Choosing the right method is crucial for the patient [5]. In our study, both combined acupuncture and massage, and acupuncture alone reduced BW and BMI after 21 days of treatment, and the effect was prominent in the first 4 days. Given the current results and accounting for the economic strategy (time and money) in alternative therapy, MAT alone may present a reasonable option in the treatment of overweight and obesity in adults. However, the effects of long-term treatment and follow-up treatment should be assessed in future studies.
Conflicts of interest All contributing authors declare no conflicts of interest.
Acknowledgments This work was supported by the National Natural Science Foundation of China (No. 81373717 and No. 81373551), by the Fund of Open Innovation Platform in Hunan College (No. 12K084) and by the Scientific Research Fund of Hunan Provincial Science and Technology Department (No. 2012FJ4285).
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Please cite this article in press as: He J, et al., Effect of Combined Manual Acupuncture and Massage on Body Weight and Body Mass Index Reduction in Obese and Overweight Women: A Randomized, Short-term Clinical Trial, Journal of Acupuncture and Meridian Studies (2014), http://dx.doi.org/10.1016/j.jams.2014.08.001
