The purpose of this study was to compare the effects of diet and exercise vs acupuncture, diet and exercise on the body weight and related parameters of adult women.
Twenty-seven obese women with a body fat percentage of more than 30% were randomized into three groups. The first experimental group had diet and exercise, whereas the second experimental group had diet, exercise and acupuncture. The control group received no intervention at all. The study period lasted for 8 weeks. Body weight, skin fold thickness, body mass index and fat mass were measured before and after 8 weeks.
Body mass index and fat mass, decreased significantly (P<0.05) in both experimental groups when compared with the control group. However, there was no significant difference between the two experimental groups. Changes in lean body mass after 8 weeks were not significantly different from those in the control group.
It is concluded that acupuncture combined with diet and exercise does not generate larger reductions in body weight, fat mass or body mass index than diet and exercise alone.
Obesity and overweight are associated with many serious conditions, including type 2 diabetes, hypertension and coronary heart disease.1 Adults who gain 5.0–7.9 kg are 1.9 times more likely to develop type 2 diabetes and 1.25 times more likely to develop coronary heart disease than those who lose weight or maintain a stable weight after the age of 18 years. Gaining 11–20 kg weight in adulthood increases the risk of an ischemic stroke by 1.69–2.25 times. Obesity can also impair physical functioning, reduce quality of life and adversely affect mental health.1
A number of factors may contribute to the development of obesity including genetic predisposition, endocrine factors and physical inactivity. However, when energy intake exceeds energy expenditure, weight gain is inevitable.2, 3, 4 There are several methods for losing weight, including diet,9, 10 exercise,4, 5, 6 acupuncture,7, 8 drugs,9, 10 behavioral therapy11, 12 and surgery.13 It is claimed that acupuncture has useful long-term effects on body weight.14 It has been used in China for several thousands of years and in the West for about 300 years.15 The use of acupuncture as a treatment of obesity is, however, relatively new.16 In recent decades, there has been a growing interest in this application.17
According to traditional Chinese medicine, the stimulation of specific acupoints can influence the function of internal organs. For example, it is claimed that needling the ear-point ‘stomach’ blocks signal transmission from the hypothalamus, depresses the sensation of hunger and thus restricts food intake. It has also been shown that acupuncture can increase the levels of serotonin and relaxing neurotransmitter endorphins, which could assist in controlling appetite.14
When obese individuals follow a low-calorie diet, they experience adverse effects such as loss of lean body mass, tiredness and psychological symptoms.18 When exercise is used to treat obesity, weight gain can occur after the cessation of exercise.19 If these two treatments are combined, they may be more helpful than any one approach in isolation.13, 16 To determine the effectiveness of triple therapy, Huang et al.20 investigated the effects of diet, aerobic exercise and acupuncture. These authors found satisfactory body weight reductions and a good maintenance of target weight after the discontinuation of this treatment. This encouraging result requires independent verification.
This study was designed to investigate the effectiveness of exercise plus diet with and without additional acupuncture on fat mass, body mass index, lean body mass and weight loss in obese women.
Participants and methods
Twenty-seven obese women (age, 25±10 years) with a body fat percentage of more than 30 were recruited through advertisements. The participants' names were listed randomly and were randomly assigned to three groups: (1) experimental group one (diet and exercise) (DE), (2) experimental group two (diet and exercise and acupuncture) (DEA), and (3) control group (no intervention). The participants' characteristics for each group are presented in Table 1. The university's ethics committee initially approved the experimental procedures and study protocols, which were fully explained to all participants, and a written consent form was signed after having read and understood the details of the experiments.
All participants completed a descriptive questionnaire including general information, such as gender, age and education. Physiological characteristics and body composition measurements were subsequently recorded. All participants in the two experimental groups took part in a battery of aerobic and resistance exercises for 8 weeks, three sessions per week. These participants also followed a diet recommended by a nutritionist based on each participant's resting energy expenditure. In addition to exercise and diet, the participants in the experimental group 2 (DEA) received regular acupuncture. The control group (C) attended the laboratory only for pre- and post-test measurements and received no medical or other interventions at all.
The participants were asked to follow a low-calorie diet for 8 weeks. The diet consisted of 500 kcal per day energy less than the individual daily energy requirements. The resting energy expenditure was calculated using the equation by Mifflin et al. as reported by Mahan and Stump,4 and was used to determine the amount of food per day for each participant. The 8-week dietary program for each participant was planned by a nutritionist based the participant's energy expenditure. The diet was prescribed and the participant's compliance was checked every other day by the nutritionist. Macronutrient energy distribution was 25–30% fat, 50–55% carbohydrate and 15–20% protein.20
At the beginning of each exercise session, the participants performed general warm-up for 10 min followed by 20 min of running at 70% of the maximal heart rate (220 minus age in years). This was followed by a resistance exercise protocol consisting of three sets of 20 repetitions at 80% of 10 repetitions maximum for leg press, chest press and abdominal curls. The participants were allowed 1-minute rest between each set of exercises. At the end of the program, the participants performed 10 min stretching exercises. The exercise program was performed 3 days per week for 8 weeks. To determine the muscular strength (maximal strength), 10 repetitions maximum were taken as the maximum amount of weight that could be lifted 10 times throughout a complete range of motion. The 10-repetition maximum was achieved by increasing the load by 5 kg after each successful set (10 lifts per set) until the maximum load sustainable was obtained.
After skin sterilization using an alcohol pad, steel needles were inserted into selected acupoints and fixed by an adhesive tape. These points were ear points of hunger,21 Shenmen22 and Finglong.23 Periodically needles were stimulated by hand. Each session lasted for 20 min. Trained acupuncturists performed the treatment once every week. The participants were asked to press acupoint of Shenmen using lentil seeds 10 times during 30 min before each meal and whenever they felt hungry.
Body composition measurement
Skin fold thickness was measured to the nearest 0.5 mm, at six predetermined sites (triceps, subscapula, suprailiac, calf, abdomen and thigh) using Harpenden caliper (Assist Creative Resources Ltd., Wrexham, UK). All measurements were taken on the right side of the body. Bioelectrical impedance was used to measure the percentage of fat mass. Body mass index was determined before and after 8 weeks.
All statistical analyses were performed using the software statistical package SPSS version 12 (SPSS, Chicago, IL, USA). A two-way ANOVA (3 × 2) with repeated measures across conditions and times was employed to examine the differences in mean values for body mass, lean body mass and body mass index. When ANOVA indicated the presence of a significant difference, post hoc comparisons using Bonferroni corrections were applied to determine pairwise differences. Wilks' lambda multivariate tests (MANOVA) were performed to assess differences in skin fold thickness in various points (suprailiac, subscapula, triceps, calf, abdomen and thigh) among the three groups. Values are presented as means±s.d. The level of significance in all statistical analyses was set at P<0.05.
Fat mass decreased significantly in DE and DEA groups from 22.0±4.9 to 19.4±3.8 kg and from 26.4±3.8 to 22.8±3.0 kg, respectively (Figure 1). These changes were significantly different from those noted in the control group. However, there was no significant difference between the two experimental groups. For lean body mass, neither intra-group changes nor inter-group differences were significant (Figure 2). Body mass index decreased from 27.0±2.4 to 25.8±1.5 and from 29.6±2.4 to 28.2±2.3 in DE and DEA groups, respectively. Although the body mass index data for the two experimental groups were significantly different from the control group, no significant difference was observed between the two experimental groups (Figure 3). Triceps, calf, subscapula and suprailiac skin folds did not change significantly in any of the groups. Abdominal and thigh skin folds (central region) decreased significantly more in DE and DEA groups than in the control group (Table 2).
Our results suggest that fat reduction occurs in the central region of the body with both experimental treatments. This result is similar to earlier findings24 and may be related to the physiological effects of diet therapy combined with regular exercise. The abdominal adipocytes of women have a 40 times lower α2-adrenergic antilipolytic sensitivity than gluteal adipocytes, but adenosine receptor sensitivity is similar at both sites.24, 25, 26 The visceral adipose tissue has been shown to be more sensitive to lipolytic stimuli than subcutaneous depot fat. In addition, cells from visceral adipose tissues are less sensitive to the inhibitory action of insulin on lipolysis than adipose cells from subcutaneous adipose tissue.27, 28
The application of acupuncture was claimed to increase the feeling of fullness, whereas diet or exercise did not affect this sensation.22, 24 Electro acupuncture has been claimed to motivate some participants to follow a low-calorie diet.21 In addition to maintaining or increasing the lean body mass, acupuncture is being promoted for body mass and fat mass reduction. Our study shows no significant differences between experimental groups 1 and 2 for body mass index and lean body mass and are in contrast with the above findings. This casts doubt on the earlier studies.20, 22
Huang et al.20 found an 86.7% effectiveness rate of triple therapy (diet, exercise and acupuncture) with an average of 5.5 kg weight reduction per week. In this study a very similar diet protocol was used, but resistance training and body acupuncture were added to aerobic exercise. Our findings fail to confirm those of Huang et al.;20 we were not able to detect significant differences between the two experimental groups. The discrepancy could be because of the participants' status, selected acupoints or duration of treatment. Alternatively, acupuncture may not be an effective treatment of obesity. This hypothesis is supported by two systematic reviews of clinical trials29, 30 that assessed the evidence from randomized controlled trials and systematic reviews of complementary therapies for reducing body weight and showed that acupuncture or acupressure is not effective in reducing appetite or body weight. Moreover, it has been pointed out repeatedly that Chinese trials of acupuncture are positive in 100% of the cases.31 As most of the positive acupuncture trials on weight loss are of Chinese origin, this type of bias might be important.
Being overweight and gaining weight have psychosocial consequences. A weight gain of 10 kg or more during adulthood increases the risk of a variety of illnesses ranging from cardiovascular disease to cancer and compromises the participant's quality of life.1 Modern lifestyles have systematically reduced the amount of physical activity from our lives. More and more leisure time is spent in watching television and eating snacks. These lifestyle variables correlate with obesity.32 Weight loss programs that rely solely on diets have poor long-term outcomes. Sometimes dieting leads to depression, a sense of failure or serious eating disorders.33 Furthermore, even if the participant can accept a lower-calorie diet, weight loss is limited because of a decrease in the resting metabolic rate.20 A reduction of 10% of energy from fat is associated with a reduction of 16 g per day in body weight.2 Exercise increases energy expenditure for hours after the completion of the exercise.7 The combination of diet and exercise is therefore the optimal treatment for obesity.34 The assumption that the addition of acupuncture is effective was, however, not confirmed by the results of this study.
Our study has several limitations. Its sample size is small. Therefore it is conceivable that, because of a type 2 error, the effects of acupuncture were not noted. The study period was short considering that any approach to body weight normalization must be long term. We only included women and strictly speaking, our results therefore cannot be extrapolated to men. The control group had no intervention at all; therefore non-specific effects cannot be excluded.
It is concluded that the combination of regular exercise with a hypocaloric diet reduces body weight in obese women. The addition of acupuncture to this regimen does not add, according to our findings, a substantial advantage.
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Nourshahi, M., Ahmadizad, S., Nikbakht, H. et al. The effects of triple therapy (acupuncture, diet and exercise) on body weight: a randomized, clinical trial. Int J Obes 33, 583–587 (2009). https://doi.org/10.1038/ijo.2009.41
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