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0J Acupunct Meridian Stud 2015;
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Journal of Acupuncture and Meridian Studies
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ELSEVIER
I REVIEW ARTICLE |
Herbal Acupuncture for the Treatment of Obesity
Min-Ho Nam Seung-Wook Lee 2,y, Hyun-Young Na 2, Jeong-Hwa Yoo 2, Sun-Ho Paik 2, Kwang Seok Ahn 1, Young-Min Ahn 2, Se-Young Ahn 2, Seung-Hoon Choi3'*, Byung-Cheol Lee 2'*
1 Department of Pathology, College of Korean Medicine, Kyung Hee University, Seoul, South Korea
2 Department of Internal Medicine, College of Korean Medicine, Kyung Hee University, Seoul, South Korea
3 Department of Medicine Consilience, Dankook University, Yongin, South Korea Available online ■ ■ ■
Received: May 26, 2015 Revised: Sep 3, 2015 Accepted: Sep 9, 2015
KEYWORDS
herbal acupuncture;
pharmacopuncture;
obesity
Abstract
Obesity is the state of excessive body fat accumulation and is mainly caused by consuming more calories than are burned through physical activity. Herbal acupuncture (HA), also known as pharmacopuncture, has been increasingly used in clinics of Korean medical to alleviate obesity. This review analyzed four clinical studies and 16 animal studies on the effectiveness of HA as a treatment for obesity. Clinical evidence suggests that various kinds of HA might be beneficial for treating obesity; however, further investigations with well-designed, evidence-based, randomized clinical trials are needed. Animal studies support the idea that HA might be beneficial for the treatment of obesity and provide possible mechanisms, such as anti-inflammation, antioxidation, modulating lipid metabolism and so on, to explain the effect of HA on obesity. This review, based on the evidence collected, suggests that HA could have a beneficial effect for alleviating obesity by modulating inflammation, oxidative stress, lipid metabolism, leptin, and the insulin signal.
* Corresponding authors.
E-mail: choish@dankook.ac.kr (S.-H. Choi), hydrolee@korea.com (B.-C. Lee). y These authors equally contributed to this work.
pISSN 2005-2901 eISSN 2093-8152
http://dx.doi.org/10.1016/j.jams.2015.09.002
Copyright © 2015, Medical Association of Pharmacopuncture Institute.
2 M.-H. Nam et al.
1. Introduction
Obesity is a serious and rapidly growing public health problem in most countries around the world. Obesity is the state of excessive body fat accumulation, which is mainly caused by consuming more calories, especially fatty and sugary foods, than one burns off through physical activity; therefore, many behavioral lifestyle interventions have been suggested [1]. Most of them have shown positive results in short-term weight loss. However, the majority of patients failed to maintain the weight loss for more than a few years [2]. In addition, the use of Western antiobesity drugs has been limited by side effects such as negative mood changes, suicidal thoughts, and gastrointestinal or cardiovascular complications [3]. Therefore herbal medicine and acupuncture can provide an alternative therapy for this medical challenge. Recent clinical trials using herbal medicine and acupuncture have reported possible therapeutic value in treating obesity, despite controversy caused by small sample sizes and low-quality methodologies [4]. The combined treatment of herbal medicine and acupuncture also showed greater efficacy in reducing weight than a nonpharmacological control [5].
Herbal acupuncture (HA), a type of acupuncture also known as pharmacopuncture, acupuncture point injection, acupoint injection, or point injection therapy, is a modern adjunctive Korean medicine technique that injects natural herbs or biologic substances into acupuncture points to promote, maintain, or restore health and prevent disease [6]. To this point, it has primarily been applied to resolve pain-related diseases such as rheumatoid arthritis [7].
Here, we review recent progress in HA with a special focus on its efficacy, safety, and possible therapeutic value in treating obesity.
2. Clinical studies of HA and obesity 2.1. Efficacy
Four clinical studies have dealt with the efficacy of HA on people with obesity. All of the studies used different herbal decoctions, acupoints, and doses for specified effects on obesity (Table 1).
(1) Effects on losing body weight
The practical purpose of HA therapy on people with obesity is losing weight. Two clinical studies showed significant beneficial effects in reducing body weight (BW) and waist circumference (WC). Kim et al [8] examined whether or not HA using Ephedra sinica and Aconitum carmichaelii had therapeutic effects on 70 volunteers with body mass index (BMI) greater than 25. Persons with a body weight greater than 120 kg, underlying disease (liver cirrhosis, renal failure, severe diabetes mellitus with complications, etc.), and those taking obesity-inducing drugs were excluded. Twenty-four patients in the HA group and 28 individuals in the control group with normal saline injection were randomly assigned and analyzed. Because both groups underwent other common interventions together, such as
diet, electroacupuncture, herbal therapy, and exercise education, both groups showed significant decreases in BMI, BW, and WC. However, the HA group showed greater reductions in BW (-1.86 ± 1.65 kg vs. -0.94 ± 2.47 kg, p < 0.05), BMI (-0.76 ± 0.67 kg/m2 vs. -0.34 ± 1.06 kg/m2, p < 0.05), and WC (-3.30 ± 2.12 inch vs. -1.09 ± 1.32 inch, p < 0.05), than the control group.
Another study [9] investigated the therapeutic effects of HA using the Bigiheo (Piqixu, spleen qi deficiency) decoction on waist—hip ratio, nonfat mass, WC, and BMI in women. In this study, spleen qi deficiency was regarded as a critical inclusion criterion; however, the study did not include a detailed protocol. After 3 weeks of treatment, the HA group showed more significant decreases in WC (-3.36 ± 2.53 cm vs. -4.58 ± 2.54 cm, p < 0.05) and abdominal fat (-3.19 ± 6.79% vs. -5.22 ± 1.20%, p < 0.05) than the control group. In terms of abdominal nonfat mass and BMI, common interventions (diet, behavioral therapy, electroacupuncture, auricular acupuncture, herbal medicine, exercise education) showed significant effects, and HA did not show any additional effects.
(2) Effects on reducing visceral adipose tissue
One clinical study showed efficacy in reducing visceral adipose tissue. Lee et al [10] designed a clinical trial with HA using the Sobieum (Xiaofeiyin) decoction. They recruited 40 women with obesity and assigned them randomly into two groups. Computed tomography (CT) and bioelectrical impedance analysis (BIA) were used for outcome evaluation. Both the HA and control groups showed a significant decrease in BW, WC, BMI, body fat mass, and total, visceral, and superficial subcutaneous fat tissue because of the basal interventions applied to both groups. Deep subcutaneous fat tissue area (-6.17 ± 13.78 cm2 vs. -5.50 ± 12.13 cm2, p < 0.05) was the only outcome that showed a significant difference between the two groups.
By analyzing the data with Pearson's correlation, visceral fat area was significantly correlated with total fat reduction only in the HA group (0.600 vs. 0.406, p < 0.01), which means that HA using Sobieum is effective at reducing visceral fat. Visceral adiposity is a marked feature of aging and other prominent risk factors associated with obesity such as insulin resistance [11], which is highly correlated with obesity and diabetes. This clinical study suggests that HA using Sobieum could be useful in obesity treatment, especially with diabetes.
(3) Effects on metabolic rate
Lee et al [12] tested whether HA using the Bangkih-wangkitang (Fangjihuangqitang) decoction is effective against obesity. Interestingly, this study showed an increase in energy expenditure without body weight loss. The authors recruited 31 female volunteers with a BMI over 25 and divided them into two groups. They evaluated BMI, percentage of body fat, skeletal muscle mass, basal metabolic rate, total cholesterol, triglycerides, high-density lipopro-tein cholesterol, low-density lipoprotein cholesterol, blood urea nitrogen, creatinine, aspartate transaminase, and
Table 1 Summary of clinical studies reviewed in this review.
Country (language)
Numbers allocated (numbers analyzed) [dropout rate]
Mean age (Y) ± SD (range)
Inclusion criteria
et al [8]
Korea (Korean)
HA: -(24)[ ] CTL: -(28)[ ]
43.42 ± 11.18 (20-68) CTL:
46.57 ± 13.37 (20-68)
BMI > 25
Lee Korea HA: 16 (16)[0] NA (16-35) BMI > 25
et al [12] (Korean) CTL: 15 (15)[0] Female
Description of intervention Outcome Study design Main findings
measures
HA decoction: Ephedra sinica & Aconitum carmichaeli Acupoint: ST25, CV4, CV6, GB26
Dose: 0.5 mL for each acupoint
Treatment: twice a wk for 5 wk.
(Normal saline was injected for CTL group.) Dietary therapy, electroacupuncture therapy, herbal therapy, exercise education were applied equally in both groups. HA decoction:
Bangkihwangkitang decoction Acupoint: BL23, BL52, ST25 Dose: 0.2 mL for each acupoint
Treatment: 8 times for 3 wk (No injection was performed for CTL group.) Dietary therapy, physiotherapy, colonic irrigation, auricular acupuncture therapy, & electrostimulation therapy were applied equally in both groups.
BMI RCT HA group showed a
BW single-blind significant decrease in
WC BMI, BW, WC than CTL
group.
BMI, percentage of -body fat, skeletal muscle mass, basal metabolic rate, TC, TG, HDL, LDL, BUN, Creatinine, AST, ALT
BMI & percentage of body fat were significantly decreased in both groups. Skeletal muscle mass & basal metabolic rate had significantly increased in only HA group.
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Table 1 (continued)
Country (language)
Numbers allocated (numbers analyzed) [dropout rate]
Mean age (V) ± SD (range)
Inclusion criteria
Description of intervention
Outcome measures
Study design
Main findings
Cha [9]
Korea (Korean)
HA: 21 (21)[0] CTL: 21 (21)[0]
HA: 35.5 CTL: 36.5
Lee et al.
Korea [10] (Korean)
HA: 20 (18)[2] CTL: 20 (18)[2]
NA (20-55)
Female Spleen qi deficiency sVndrome
BMI > 25 WC > 85m Pre-menopausal women
HA decoction: Bigiheo decoction
Acupoint: 9 to 10 acupoints including CV12, CV10, CV4, ST25
Dose: 0.2 mL for each acupoint
Treatment: twice a wk for > 3 wk.
(No injection was performed for CTL group.) Dietary therapy, behavioral therapy, electroacupuncture therapy, auricular acupuncture therapy, herbal therapy, exercise education were applied equally in both groups
HA decoction: Sobieum decoction
Acupoint: No-specific acupoint. Abdomen. Dose: 4 mL
Treatment: twice a wk for 6 wk.
(Normal saline was injected for CTL group.) Dietary therapy (1200 kcal/ d), physical therapy (30 min walking, 3 times a wk) were prescribed for both groups.
WHR, WC, non-fat mass, BMI
BW, WC, body fat mass, total fat area, visceral fat area,
subcutaneous fat area, blood pressure, FBS, TC, TG, HDL, FFA, KEAT-26, BPAQ, SRRS, SRI, BDI, SES
single-blind
HA group showed a significantly greater decrease in WHR & WC. Change of non-fat mass, BMI showed no significant difference between two groups.
BW, WC, BMI, body fat mass, total fat area, visceral fat area, &superficial subcutaneous fat area were significantly decreased in both groups. Deep subcutaneous fat area was decreased significantly only in the HA group.
Only HA group showed a significant correlation between visceral fat area & total fat area reduction.
ALT = alanine transaminase; AST = aspartate transaminase; BDI = Beck Depression Inventory; BL = bladder; BMI = body mass index; BPAQ = Baecke Physical Activity Questionnaire; BUN = blood urea nitrogen; CTL = control; CV = conception vessel; FBS = fasting blood sugar; FFA = free fatty acid; GB = gall bladder; HA = herbal acupuncture; HDL = high-density lipoprotein cholesterol; KEAT-26 = the Korean version of Eating Attitude Test-26; LDL = low-density lipoprotein cholesterol; NA = not attained; RCT = randomized clinical trial; SD = standard deviation; SES = Self Esteem Scale; SRI = Stress Response Inventory; SRRS = Social Readjustment Rating Scale; ST = stomach; TC = total cholesterol; TG = triglyceride; WC = waist circumference; WHR = waist-hip ratio.
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Herbal Acupuncture for the Treatment of Obesity 5
alanine transaminase. Except for skeletal muscle mass and basal metabolic rate, HA did not show any significant superiority compared to the control group. The HA group showed significantly higher skeletal muscle mass (39.03 ± 5.24 kg vs. 34.41 ± 4.12 kg, p < 0.05) and basal metabolic rate (1458 ± 135.2 kcal vs. 1346 ± 130.7 kcal, p < 0.05) than the control group at the end of the study. Because the low quality of this study indicates low reliability, additional studies are needed to evaluate the therapeutic effect of HA using Bangkihwangkitang.
2.2. Acupoint selection
Clinical studies have used acupoints ST25, CV4, CV6, CV10, CV12, GB26, BL23, and BL52. ST25 and CV4 were used in three [8,9,12] and two [8,9] studies, respectively, and each of the other points was used once. ST25, which is on the stomach meridian and on the abdomen, is a frequently used acupoint for various gastrointestinal track disorders. Like ST25, the other acupoints are all on the abdominal region, with the exceptions of BL23 and BL52. BL23 and BL52 are well known for dealing with endocrinological disorders. In the study by Lee et al [12], HA treatment on BL23 and BL52 showed increased metabolic rate.
Due to the possibility of identifying multiple patterns for a single disease in traditional Korean medicine, applied acupoints and herbal decoctions vary. The clinical studies we reviewed also used various acupoints and herbal decoctions. Therefore, it is difficult to conclude that HA using any specific acupoints or kinds of herbs has a beneficial effect in treating obesity.
Finally, none of the studies we reviewed evaluated Deqi sensation. Even though little evidence supports the relationship between acupuncture efficacy and Deqi so far, Deqi has been broadly accepted as a critical concept for acupuncture efficacy [13]. If studies evaluated Deqi sensation in HA treatment, it would be safer to conclude that HA therapy is effective as a kind of acupuncture therapy.
2.3. Herbs
Kim et al [8] used HA composed of Ephedra sinica and Aconitum carmichaelii. Both herbs are widely used for tonifying yang and dissipating cold that hinders energy expenditure. Lee et al [10] used Sobieum HA, which includes Platycodon grandiflorum, Ephedra sinica, Morus alba, Liriope platyphylla, Scutellaria baicalensis, and Prunus armeniaca. Sobieum is a decoction known to boost the lipolysis of adipose tissue and inhibit lipid absorption in the intestine [14]. In this review, two studies used Ephedra sinica, which is well known for its antiobesity effect, as demonstrated in many human and animal studies [15—18]. Because Ephedra sinica has side effects such as heart palpitations and dyspepsia [19], combination with other drugs would be helpful. In this regard, Sobieum contains not only Ephedra sinica but also other herbs with antiobesity potential, such as Platycodon grandiflorum [20—23], Morus alba [24,25], Liriope platyphylla [26], and Scutellaria bai-calensis [27,28].
Lee et al [12] applied HA using Bangkihwangkitang to obesity treatment. Bangkihwangkitang is a composition of Stephania tetrandra, Astragalus membranaceus, Atractylis koreana, Glycyrrhiza uralensis, and Zingiber officinale. This decoction has been known to dispel dampness and tonify the spleen; therefore, it has long been used for treating obesity in traditional Korean medicine.
HA using the Bigiheo decoction [9] was used to tonify spleen qi. This decoction is composed of Panax ginseng, Astragalus membranaceus, Dioscorea batatas, Atractylodes japonica, Poria cocos, Citrus unshiu, Zizyphus jujube, and Glycyrrhiza uralensis.
According to traditional Korean medical theories, obesity can be caused by phlegm dampness, spleen deficiency, stomach heat, liver depression, and kidney deficiency [4]. Bangkihwangkitang and Bigiheo herbal decoctions are both known to tonify qi and spleen function. In particular, Astragalus membranaceus, used in both decoctions, is known to boost spleen qi and improve obesity and insulin resistance [29,30]. In human studies, herbal decoctions were preferred to a single herb. Combinations of multiple herbs hinder mechanism studies of HA. In spite of this limitation, many of the herbs used for HA therapy have already been proven to have antiobesity effects in previous studies.
2.4. Safety issues
Safety issues of HA have to be discussed in two aspects. One is adverse events induced by needling, and the other is events caused by herbs. In this review, none of the four papers reported any adverse events from HA.
Acupuncture is known to be a safe intervention in the hands of skilled physicians. A prospective investigation reported only 7.10% occurrence of nonserious adverse events and 0.006% occurrence of serious events among 97,733 cases [31]. In 16 studies on acupuncture treatment for obesity, only six reported side effects such as skin bruises and redness. More serious complications have been rarely reported, for example abscess formation and cardiac tamponade, but those were limited to elderly immunocom-promised patients and those with severe diabetes [4].
Even though HA did not raise any safety issues in the four clinical studies and herbal medicine is also known to be a relatively safe treatment throughout its long history, HA is not completely free from the possibility of toxicity or adverse effects. For instance, Ephedra sinica and Aconitum carmichaelii are notorious for their side effects of palpitation, nausea, vomiting, breathing problems, etc. Although no adverse events occurred in the four clinical studies, these herbs should be used in a proper dose and under the supervision of skilled physicians.
2.5. Limitations
Because all the studies used basal interventions such as dietary therapy, physical therapy, and exercise education for both HA and control groups, accurate evaluation of HA efficacy was difficult. Primary outcomes were not consistent between studies; therefore, direct comparison between various kinds of HA is impractical. Moreover, the
6 M.-H. Nam et al.
sample sizes of the four studies were too small to generalize. Despite these limitations, HA treatment of obesity does seem to be beneficial.
3. Experimental evidence
Recent experimental studies support the idea that HA has beneficial effects in treating obesity. HA using various herb extracts was shown to be effective for weight loss and lowering blood glucose and blood lipids. Those therapeutic effects were caused by multi-faceted mechanisms, such as anti-inflammatory effects, antioxidative effects, and modulation of lipid metabolism. The experimental evidence could provide a mechanistic understanding of the effects of HA on obesity.
3.1. Efficacy
(1) Anti-inflammatory effect
Obesity and inflammation are associated with each other. Obesity induces a chronic, low-grade inflammatory response initiated by excess nutrients in metabolic cells [32]. This inflammation, also called metaflammation, generally causes insulin resistance through inflammatory kinases, c-Jun N-terminal kinases (JNK), IkB kinase (IKK), and protein kinase R (PKR), which can aggravate obesity [32]. Since the first study showing overexpression of tumor necrosis factor-alpha (TNF-a) in the adipose tissue of mice with obesity [33], many subsequent studies have provided a link between obesity and chronic inflammation. In addition to TNF-a, several other inflammatory mediators and cytokines, such as interleukin (IL)-1 b and IL-6, are reportedly increased in obese conditions [34].
Many studies have suggested that acupuncture might improve inflammatory conditions by regulating several pro-or anti-inflammatory mediators [35]. Not only acupuncture, but also HA is supported as a potent anti-inflammatory therapy for obesity as evidenced by several experiments [36—40]. HA was shown to be effective in reducing TNF-a, IL-1 b, and/or IL-6 in mice with obesity using extracts of Prunella vulgaris, Chrysanthemum indicum, Radix puerar-iae [37], Radix ginseng [36], and Lumbricus [38] on BL11 and ST36, BL18 and LI11, and ST36 and CV12, respectively. One in vitro study showed that mixed extracts of Radix Ginseng, musk, Ursi Fel, and Bovis Calculus inhibited inducible nitric oxide synthase, cyclooxygenase-2, and nuclear factor-kappa B expression induced by lipopolysac-charide in the 3T3-L1 cell line, which is consistent with the in vivo effect of weight loss [36].
(2) Antioxidative effect
In obese conditions, as fat tissue increases, adipocytes generate increasing levels of oxidative stress, such as reactive oxygen species (ROS), that induce secretion of inflammatory molecules [41]. Oxidative stress leads to insulin resistance, which again aggravates obesity [41]. Simultaneously with ROS production, antioxidants such as superoxide dismutases (SOD), glutathione (GSH), gluta-thione peroxidase (GSH-Px), and catalase are decreased
[42]. Therefore, several studies suggest that reducing oxidative stress or increasing antioxidants might be beneficial in treating obesity [43].
Several pieces of experimental evidence suggest that HA can increase antioxidants such as SOD, GSH-Px, and cata-lase in obese mice. HA using extracts of Prunella vulgaris, Chrysanthemum indicum, Radix puerariae [37], Radix ginseng [44], and Phaseolus angularis [45] significantly increases SOD, GSH-Px, and catalase levels in mice with obesity and reduces body weight and body fat. HA using the extract of Lumbricus [38] increases SOD and catalase levels but not GSH-Px with reduced body weight.
(3) Effects on modulating lipid metabolism
In physiological conditions, adiponectin is exclusively secreted by adipocytes and activates adenosine monophosphate-activated protein kinase (AMPK). In turn, activation of AMPK inactivates acetyl-CoA carboxylase (ACC) by phosphorylation and blocks transformation of acetyl-CoA into malonyl-CoA. Therefore, carnitine palmi-toyltransferase 1 (CPT1) is activated, prompting adequate mitochondrial fatty acid oxidation. However, AMPK phosphorylation also activates peroxisome proliferator-activated receptor (PPAR)-a, which leads to the oxidation of fatty acids and decreasing triglycerides [46].
However, in obese conditions, increased adiposity leads to low plasma levels of adiponectin production, resulting in decreased AMPK activity. Inactivation of AMPK reduces PPAR-a activity and phosphorylation of ACC [46], inducing hyperglycemia [47].
Several reports suggest that abnormal lipid metabolism in obese animal models can be recovered by HA treatment. HA using Rhizoma Atractylodis [48] and Artemisia capillaries [49] was reported to boost AMPK phosphorylation, thus inhibiting the synthesis of fatty acids and promoting their oxidation. Adiponectin [36,50,51] and PPAR-g [36], which are critical for regulating fatty acid storage and glucose metabolism [44], were also shown to be increased by HA treatment. Moreover, HA treatment with Artemisia capillaries was effective in increasing CPT1, which was followed by AMPK phosphorylation [49]. Apolipoprotein B, overproduction of which leads to insulin resistance and obesity [52,53], was reduced by HA using Phaseolus angularis [45].
Taken together, the evidence suggests that acupoint injection of herbal extracts might modulate systemic lipid metabolism. However, HA treatment is profoundly dependent on the kinds of herbal extracts used; therefore, it is difficult to conclude that most HA used to treat obesity is working on the lipid metabolism. Most studies show only one or two pieces of the whole metabolism picture. Further studies should investigate the beneficial effects of using HA to modulate lipid metabolism with other extracts.
(4) Effects on insulin signal
It is well known that insulin resistance commonly coexists with obesity and that the two conditions aggravate each other [54]. Hyperinsulinemia is thought to be a result of obesity and insulin resistance. However, a recent study
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Herbal Acupuncture for the Treatment of Obesity 7
reported that hyperinsulinemia drives obesity and its complications [55]. Keeping insulin levels low is critical to maintaining energy expenditure in white adipose tissue; therefore, reducing insulin levels is beneficial in treating obesity [55].
(5) Effect on leptin
Several studies suggest that HA is beneficial for reducing serum insulin levels and insulin resistance. Using the herb extracts of Rhizoma Atractylodis [48] or Artemisia capillaries [49] at BL23 or BL20, respectively, was especially effective for reducing both serum insulin levels and insulin resistance. HA using mixed extracts of Radix Ginseng, musk, Ursi Fel, and Bovis Calculus at BL20 was also reported to reduce serum insulin levels [36].
Leptin, a key hormone of obesity produced by adipocytes, inhibits hunger [38]. Obesity is characterized by low leptin sensitivity among neurons in the arcuate nucleus of the hypothalamus and increased serum leptin levels [36]. Therefore, regulating leptin levels and leptin sensitivity is thought to be pivotal for treating obesity [45].
Three experimental studies investigated whether HA exhibits a significant effect in reducing serum leptin levels. Consistent with the clinical effects of HA, HA with Prunella vulgaris, Chrysanthemum indicum, Radix puerariae [37], and Phaseolus angularis [45] was also reported to reduce serum leptin levels in parallel with its weight loss effect. However, HA using Eriobotryae folium did not decrease leptin levels [50]. Those results imply that the therapeutic mechanism of HA could be dependent on the herbs. In future studies, leptin sensitivity should be considered as a more important factor in determining improvement of obesity rather than plasma levels of leptin.
3.2. Acupoint selection
Obesity is a medical condition characterized by excess body weight and body fat. As mentioned above, it has been conceptualized in various ways, such as a spleen deficiency with dampness encumbrance, spleen-stomach dampness-heat, liver qi depression, spleen-kidney yang deficiency, dual deficiency of qi and blood, and food accumulation. Based on those patterns of obesity conceptualized by traditional Korean medical theories, various acupoints have been applied to improve obese conditions in humans and animals.
Unlike the clinical studies, which mainly used acupuncture points on the abdomen, experimental research used more challenging points, such as those located on the lower limbs and back. Those acupuncture points are known to modulate the digestive system (BL20 [36,49,56,57], BL21 [58], ST36 [37,38,45,59], ST40 [60], SP9 [60], LI11 [44,45], CV12 [38,59]), control liver qi (BL18 [44]), affect the brain (BL11 [37]), or modulate the endocrine system (BL23 [48]). Those acupoints were previously reported to be effective for ameliorating obesity by acupuncture stimulation [49]. BL20 and BL21, on the bladder meridian, have a potent effect for modulating the spleen and stomach. ST36, SP9, LI11, and CV12, located on the stomach meridian, spleen meridian, large intestine meridian, and conception vessel,
respectively, are also known to tonify the qi of the spleen and stomach. ST40, on the stomach meridian, is a representative acupoint for treating phlegm, which is another major cause of obesity [46]. Even though the evidence shows that HA has beneficial effects for treating obesity, clinical and experimental research has used dissimilar acupoint selection. In future studies, the mechanism of frequently used acupoints in clinics needs to be studied experimentally.
3.3. Herbal medicine
A variety of herbs were used in HA to treat obesity. Most experimental studies used a single herb to confirm its effects. Because several different etiologies can cause obesity, medicinal herbs with various efficacies were used. To resolve dampness in the spleen and stomach, researchers chose Rhizoma atractylodis [48], Artemisia capillaries [49], Semen Coicis [60], and Eugenia caryophyllata [51], whereas to digest accumulated food, extracts of Semen Raphani [56], Fructus Crataegi [58], and Fructus Hordei [61] were injected into the acupoints. To tonify qi and blood, researchers used Radix Glycyrrhiza [62], Radix Ginseng [36,44], Radix Astragali, and Angelica gigas [59], and they used Eriobotryae Folium [50], Prunella vulgaris, Chrysanthemum indicum, Radix puerariae, Phaseolus angularis [37], and Lumbricus [38] to clear the heat of the spleen and stomach. Many of these extracts have previously been reported to have beneficial effects on treating obesity [50]. However, acupoint injection of extracts is different from oral administration; therefore, the mode of action still needs to be elucidated in further studies.
4. Conclusion
In this article, we reviewed four clinical studies and 16 animal studies on the therapeutic effects of HA for obesity. All of the clinical studies showed that various kinds of HA have significant benefits for treating obesity. The therapeutic effect might come through anti-inflammatory and antioxidative action or the modulation of lipid metabolism or insulin and leptin signals, as investigated in in vivo and in vitro studies. Taking all the evidence together, we suggest that HA could be a therapeutic option for treating obesity. Further clinical and experimental studies with standardized methodologies should be conducted to test the efficacy of HA.
Acknowledgments
This study was supported by the Traditional Korean Medicine R&D program funded by the Ministry of Health & Welfare through the Korea Health Industry Development Institute (KHIDI) (HI13C0700).
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