Beagle Weight Loss Exploring the Benefits of Acupuncture
Acupuncture Therapies for Individuals with Overweight or Obesity: An Overview of Systematic Reviews
Introduction
The prevalence of overweight and obesity is increasing rapidly around the world.1 Changes in the food environment and food systems as well as reduced opportunities for physical activity often account for the high incidence of people who are affected by overweight and obesity.2 It is estimated that more than one hundred million (5%) children and over six hundred million (12%) adults are affected by obesity worldwide.3 In 2017, China and India had the largest population of children with obesity, and the United States and China had the highest number of adults with obesity.3 Overweight and obesity is a risk factor for numerous chronic diseases, including cardiovascular disease, diabetes, chronic kidney disease and cancer.4,5 A high body mass index (BMI) greater than 25 kg/m2 (defined cut-off of overweight) accounted for four million deaths globally, and more than two-thirds of deaths were due to cardiovascular disease.3
Reduced energy intake, increased physical activity and behavioral change are the fundamental approaches to weight loss and weight maintenance recommended in almost all international guidelines.68 In addition to lifestyle therapy, pharmacotherapy is a vital alternative or adjunct method for losing weight.8,9 Currently, among the five long-term drug therapies approved by the US Food and Drug Administration, only orlistat is available worldwide.10 One recent study found that all the approved drugs for anti-obesity were associated with higher odds of weight loss by more than 5%.11 However, even though anti-obesity drugs can help people to lose weight, few patients are reluctant to use these drugs because of concerns about safety.9 Actually, pharmacotherapy of obesity has a long history populated with multiple unsatisfaction, which is mainly from the concerns of side effect, such as headache, dizziness, insomnia, nausea, constipation, diarrhea, and concerns of potential risk about cardiovascular disease, stroke, hypertension, etc.9,10 Some future candidate drugs for anti-obesity appear to be promising but there are still considerable barriers and challenges.12,13
In recent years, acupuncture therapy has gained popularity as a treatment for weight loss. There is also a number of clinical trials and systematic reviews that evaluate acupuncture for overweight and obesity.14,15 However, interpreting evidence in relation to acupuncture treatment is challenging due to a limited number of high-quality trials with adequate treatment durations. The aim of this overview is to critically evaluate and synthesize published systematic reviews and provide guidance for future research.
Results
The search identified 616 potentially relevant systematic reviews and 581 titles/abstracts were screened after duplicate removal (). 77 full-text articles were assessed for eligibility and 38 systematic reviews were included in this overview. Results of the included reviews are presented in (details of the individual studies can be found in Supplementary Material: Appendix 3). The summarized AMSTAR-2 scores and ROBIS scores are presented in (further justification statements are presented in Supplementary Material: Appendix 4 and Appendix 5). All excluded reviews are listed in Supplementary Material: Appendix 6. The 38 included reviews14,15,1853 were published between 2009 and 2020. The reviews were mostly conducted in China (33 reviews)14,15,18,19,2125,2729,3133,3653 and one each from Australia,26 Iran,30 Korea,35 Canada34 and Brazil.20 The reviews assessed the following acupuncture therapies, including auricular acupoint stimulation (7 reviews),20,23,31,33,37,43,52 catgut embedding (6),19,22,25,32,38,46 abdominal acupuncture (2),28,32 electroacupuncture (2),15,49 laser acupuncture (1).30 The other 20 reviews14,18,21,24,26,27,29,3436,39,40,42,44,45,47,48,50,51,53 did not investigate a particular type but assessed any form of acupuncture. Anthropometry outcomes were common, such as BMI (34 reviews),14,15,1823,2640,42,43,4553 BW (30),14,15,1820,22,23,26,2940,42,43,45,4753 WC (21),14,18,22,23,2732,36,38,42,43,4649,52,53 BFM (12),14,18,23,27,2931,37,40,42,43,52 hip circumference (13),22,23,27,2931,38,42,43,47,49,52,53 and adverse events were investigated in 27 reviews.14,15,18,19,2123,2532,34,35,37,3943,45,47,48,51 All of the reviews, except two,30,37 conducted meta-analysis. The Cochrane Collaboration's tool for assessing risk of bias was used in 26 reviews14,15,1820,22,2529,3133,3540,45,46,4851 and the Jadad score in 12 reviews.21,23,24,30,34,4144,47,52,53 A total of 324 clinical trials were included in the reviews and 109 (33.6%) were included in more than one review.
Table 1
Summary of the Included Systematic Reviews
| Author, Year | Country | No. of Studies (No. of Participants) | Study Designs | Intervention | Control | Outcomes | Meta-Analysis | Risk of Bias |
|---|---|---|---|---|---|---|---|---|
| Cho 200934 | Canada | 31 (3013) | RCTs | Any acupuncture therapy alone or acupuncture combined with control therapies as an add-on treatment | No Tx, sham/plac acu, drugs, lifestyle interv. (such as diet or exercise) | BW, BMI, AEs | Yes | Jadad |
| Lin 200929 | China | 8 (1017) | RCTs | Any acupuncture therapy | Drugs | Effective rate, BMI, BW, HC, WC, WHR, BFM, weight regain rate, serum leptin | Yes | Cochrane |
| Yu 201044 | China | 8 (958) | RCTs | Any acupuncture therapy | Drugs | Effective rate | Yes | Jadad |
| Sui 201242 | Hong Kong China | 44 (4167) | RCTs | Acupuncture therapies used alone^ | No Tx, sham/plac acu, drugs, lifestyle interv. (such as diet or exercise) | BW, BMI, WC, HC, BFM, blood lipids, blood glucose, insulin sensitivity, appetite, relapse of weight regain, AEs | Yes | Jadad |
| Li 201324 | China | 11 (1257) | RCTs | Any acupuncture therapy | Non-acupuncture therapy, including diet, exercise, drugs and surgery | Effective rate | Yes | Jadad |
| Shi 201333 | China | 4 (312) | RCTs | Auricular acupressure | No Tx, diet, exercise, behavior modification | BMI, BW | Yes | Cochrane |
| Liao 201425 | China | 19 (1658) | RCTs | Catgut embedding therapy | Non-catgut embedding therapy | Effective rate | Yes | Cochrane |
| Liu 201427 | China | 27 (3043) | RCTs and Controlled trials | Any acupuncture therapy, with or without basic treatment such as diet and exercise | No Tx, sham/plac acu, drugs, with or without basic treatment such as diet and exercise | Effective rate, BMI, WC, HC, WHR, BFM, lipid level, blood sugar, fasting insulin, leptin, appetite VAS score, AEs | Yes | Cochrane |
| Guo 201522 | China | 43 (3520) | RCTs | Acupoint catgut embedding | No Tx, sham/plac acu, drugs, lifestyle interv. (such as diet or exercise), other acu interventions | BW, BMI, WC, HC, overall improvement rate, AEs | Yes | Cochrane |
| Li KX 201526 | Australia | 9 (556) | RCTs | Manual acupuncture and acupuncture combined with control therapies as an add-on treatment | No Tx, sham/plac acu, drugs, lifestyle interv. (such as diet or exercise) | BW, BMI, overall improvement rate, AEs | Yes | Cochrane |
| Li XH 201528 | China | 5 (317) | RCTs and Controlled trials | Abdominal acupuncture | Non-abdominal acu | BW, BMI, WHR, WC, WHR, effective rate | Yes | Cochrane |
| Xia 201539 | China | 15 (1082) | RCTs | Any acupuncture therapy | Placebo acu and other therapies including diet, exercise, drug therapy and Chinese herbal medicine | BW, BMI, improvement rate | Yes | Cochrane |
| Xue 201537 | China | 17 (1246) | RCTs | Auricular point taping | No Tx, placebo, other routine treatments | BMI, BW, BFM, WC, AEs | No | Cochrane |
| Yang 201541 | China | 16 (1611) | RCTs | Abdominal acupuncture | Non abdominal acupuncture | Effective rate | Yes | Jadad |
| Zhang 201550 | China | 23 (1871) | RCTs | Any acupuncture therapy | Sham acu, lifestyle interv., drug therapy | BW, BMI | Yes | Cochrane |
| Chen 201618 | China | 21 (1929) | RCTs | Any acupuncture therapy | No Tx, placebo, drugs | BW, BMI, WC, BFM, Effective rate | Yes | Cochrane |
| Ruan 201631 | China | 9 (777) | RCTs | Auricular acupoint stimulation alone or with control therapies as an add-on treatment | No Tx, sham/plac acu, drugs, lifestyle interv. (such as diet or exercise) | BW, BMI, WC, HC, BFM, WHR, TC, TG, glucose, LDL, HDL, AEs | Yes | Cochrane |
| Fang 201721 | China | 23 (1808) | RCTs | Manual acupuncture, electro-acupuncture and catgut embedding alone and combined with lifestyle therapies | No Tx, sham/plac acu, lifestyle interv. (such as diet or exercise) | BMI, AEs | Yes | Jadad |
| Namazi 201730 | Iran | 7 (369) | RCTs and Controlled trials | Laser acupuncture | No Tx, sham/plac acu, drugs, lifestyle interv. (such as diet or exercise) | BW, BMI, WC, HC, BFM, appetite parameters, AEs | No | Jadad |
| Xie 201738 | China | 16 (1284) | RCTs | Catgut embedding therapy | Non-catgut embedding therapy, including no Tx, placebo, drugs or other therapy | Effective rate, BMI, BW, WC, HC, TC | Yes | Cochrane |
| Yeh 201743 | Taiwan China | 18 (1775) | RCTs | Auricular acupoint stimulation | Sham/placebo acupuncture | BW, BMI, WC, HC, BFM, AEs | Yes | Jadad |
| Zhang, Tan 201752 | China | 11 (643) | RCTs | Auricular acupoint stimulation alone or with dietary restrictions | Sham/plac acu | BW, BMI, WC, HC, BFM | Yes | Jadad |
| Zhang, Han 201753 | China | 6 (236) | RCTs | Acupuncture therapy, including acupuncture, electro-acupuncture or auricular acupuncture | Sham acu | BW, WC, BMI, HC | Yes | Jadad |
| Cho 201819 | Hong Kong China | 5 (425) | RCTs | Acupoint catgut embedding | Sham/plac acu | BW, BMI, AEs | Yes | Cochrane |
| Kim 201835 | South Korea | 27 (2219) | RCTs | Any acupuncture therapy | No Tx, sham/plac acu, lifestyle interv. (such as diet or exercise) | BW, BMI, AEs | Yes | Cochrane |
| Wang 201836 | China | 14 (1127) | RCTs | Any acupuncture therapy | Non-acupuncture therapy | BW, BMI, WC, TG, TC, FPG, HbA1C, effective rate | Yes | Cochrane |
| Zhang YZ 201851 | China | 34 (2283) | RCTs | Manual acupuncture, electro-acupuncture, auricular acupoint stimulation, acupoint catgut embedding and warming acupuncture alone or in combination. Excluded laser acupuncture | Sham/plac acu, drugs, lifestyle interv. (such as diet or exercise) | BW, BMI, AEs | Yes | Cochrane |
| Zhang KP 201845 | China | 21 (1389) | RCTs | Any acupuncture therapy and acupuncture combined with control therapies as an add-on treatment | No Tx, sham/plac acu, drugs, lifestyle interv. (such as diet or exercise) | BW, BMI, incidence of cardiovascular events, AEs | Yes | Cochrane |
| Huang 201923 | Taiwan China | 8 (811) | RCTs and Controlled trials | Auricular acupoint stimulation alone or combined with control therapies as an add-on treatment | No Tx, sham/plac acu, lifestyle interv. (such as diet or exercise) | BW, BMI, WC, HC, BFM, AEs | Yes | Jadad |
| Mendona 201920 | Brazil | 12 (874) | RCTs | Auricular acupoint stimulation | Sham/plac acu, lifestyle interv. (such as diet or exercise) | BW, BMI | Yes | Cochrane/GRADE |
| Shan 201915 | China | 5 (380) | RCTs | Electro-acupuncture therapy, with diet and exercise as basic treatment | No Tx with diet and exercise as basic treatment | BW, BMI, Effective rate | Yes | Cochrane |
| Sheng 201932 | China | 15 (1584) | RCTs | Acupoint catgut embedding | Sham/plac acu, lifestyle interv. (such as diet or exercise) | BW, BMI, WC, AEs | Yes | Cochrane |
| Yao 201940 | China | 12 (1151) | RCTs | Any acupuncture therapy | No Tx, sham/plac acu, lifestyle interv. (such as diet or exercise) | BW, BMI, WC, BFM, serum lipids, AEs | Yes | Cochrane |
| Chen 202048 | China | 33 (2503) | RCTs | Any acupuncture therapy alone or acupuncture combined with control therapies as an add-on treatment | Sham/plac acu, lifestyle interv. (diet or exercise) | BW, BMI, WC, AEs | Yes | Cochrane |
| Gao 202049 | China | 13 (937) | RCTs or controlled studies | Electro-acupuncture | Non-eletro-acupuncture | BW, BMI, WC, HC, WHR, Body Fat Rate Reduction | Yes | Cochrane |
| Nie 202046 | China | 5 (344) | RCTs or quasi-RCTs | Catgut embedding therapy | Non-catgut embedding therapy | Effective rate, Kupperman score, BMI, WC | Yes | Cochrane |
| Pan 202047 | China | 16 (1109) | RCTs | Any acupuncture therapy | Sham acu | BW, BMI, WC, HC WHR, leptin, insulin, adiponectin, ghrelin, HOMA-IR, FPG, TC, TG, HDL, LDL, AEs | Yes | Jadad |
| Zhong 202014 | China | 8 (403) | RCTs | Any acupuncture therapy | No Tx, sham/plac acu | BW, BMI, WC, WHR, BFM, AEs | Yes | Cochrane |
Table 2
| Author, Year | Item 1 | Item 2 | Item 3 | Item 4 | Item 5 | Item 6 | Item 7 | Item 8 | Item 9 | Item 10 | Item 11 | Item 12 | Item 13 | Item 14 | Item 15 | Item 16 | Overall Statement |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Cho 200934 | Y | N | N | Y | Y | N | N | Y | N | N | Y | N | Y | Y | Y | Y | Critically low |
| Lin 200929 | Y | N | N | Y | Y | Y | N | Y | N | N | Y | N | Y | Y | N | N | Critically low |
| Yu 201044 | N | N | N | N | N | N | N | Y | N | N | Y | N | Y | Y | Y | Y | Critically low |
| Sui 201242 | Y | N | N | Y | Y | Y | N | Y | N | N | Y | N | Y | N | Y | Y | Critically low |
| Li 201324 | N | N | N | Y | Y | N | N | Y | N | N | Y | N | Y | N | Y | N | Critically low |
| Shi 201333 | N | N | N | Y | N | N | N | N | Y | N | N | N | Y | N | N | N | Critically low |
| Liao 201425 | Y | N | N | Y | Y | N | N | Y | Y | N | Y | Y | Y | Y | Y | N | Critically low |
| Liu 201427 | Y | N | N | Y | Y | Y | N | Y | Y | N | Y | N | Y | N | Y | N | Critically low |
| Guo 201522 | Y | Y | N | Y | Y | Y | N | Y | Y | N | Y | N | Y | N | Y | Y | Low |
| Li 201526 | Y | N | N | Y | Y | Y | N | Y | Y | N | N | N | Y | N | N | Y | Critically low |
| Li 201528 | N | N | N | Y | Y | Y | N | Y | Y | N | Y | N | Y | Y | Y | N | Critically low |
| Xia 201539 | Y | N | N | N | Y | N | N | Y | Y | N | N | N | Y | Y | N | N | Critically low |
| Xue 201537 | Y | N | N | Y | Y | Y | N | Y | Y | N | Y | N | Y | N | N | N | Critically low |
| Yang 201541 | N | N | N | Y | N | N | N | Y | Y | N | Y | N | Y | N | Y | N | Critically low |
| Zhang 201550 | Y | N | N | Y | N | Y | N | Y | Y | N | Y | N | Y | N | N | Y | Critically low |
| Chen 201618 | Y | N | N | Y | Y | Y | N | Y | Y | N | Y | N | Y | Y | Y | Y | Critically low |
| Ruan 201631 | N | N | N | Y | Y | N | N | Y | Y | N | N | N | Y | Y | N | Y | Critically low |
| Fang 201721 | Y | N | N | Y | Y | Y | N | Y | N | N | Y | N | Y | N | Y | Y | Critically low |
| Namazi 201730 | Y | N | N | N | Y | Y | N | Y | N | N | NR | NR | Y | Y | NR | Y | Critically low |
| Xie 201738 | N | N | N | Y | Y | N | N | Y | N | N | N | N | N | N | Y | Y | Critically low |
| Yeh 201743 | Y | N | Y | Y | Y | N | N | Y | N | N | Y | v | N | Y | Y | Y | Critically low |
| Zhang 201752 | Y | N | N | Y | N | Y | N | Y | N | N | Y | Y | Y | N | Y | Y | Critically low |
| Zhang 201753 | N | N | N | Y | N | Y | N | Y | Y | N | Y | N | N | N | Y | Y | Critically low |
| Cho 201819 | Y | N | Y | Y | Y | Y | N | Y | Y | N | Y | N | N | N | Y | Y | Critically low |
| Kim 201835 | Y | N | N | Y | Y | N | N | Y | Y | N | Y | N | Y | Y | Y | Y | Critically low |
| Wang 201836 | Y | N | N | Y | Y | Y | N | Y | Y | N | N | N | Y | Y | N | Y | Critically low |
| Zhang KZ 201851 | Y | N | N | Y | Y | Y | N | Y | Y | N | Y | Y | Y | Y | Y | Y | Critically low |
| Zhang YL 201845 | Y | N | N | Y | Y | Y | N | Y | Y | N | Y | N | N | N | N | Y | Critically low |
| Huang 201923 | Y | N | Y | N | Y | Y | N | Y | N | N | Y | N | Y | N | Y | Y | Critically low |
| Mendona 201920 | Y | Y | N | N | Y | Y | N | Y | N | Y | Y | N | N | N | Y | Y | Critically low |
| Shan 201915 | Y | N | N | Y | Y | Y | N | Y | Y | N | Y | N | N | Y | Y | N | Critically low |
| Sheng 201932 | Y | Y | N | Y | N | N | N | Y | Y | N | Y | N | N | N | N | Y | Critically low |
| Yao 201940 | Y | N | N | Y | N | Y | N | Y | Y | N | Y | N | Y | N | N | Y | Critically low |
| Chen 202048 | Y | Y | N | Y | Y | Y | N | Y | Y | N | Y | N | N | Y | Y | Y | Critically low |
| Gao 202049 | Y | N | N | N | Y | Y | N | Y | Y | N | Y | N | N | Y | Y | Y | Critically low |
| Nie 202046 | Y | N | N | Y | Y | Y | N | Y | Y | N | Y | N | Y | Y | N | Y | Critically low |
| Pan 202047 | Y | N | N | Y | Y | Y | N | Y | Y | N | Y | N | Y | Y | Y | Y | Critically low |
| Zhong 202014 | Y | Y | N | Y | Y | Y | N | Y | Y | N | Y | N | N | N | N | Y | Critically low |
Table 3
| Author, Year | 1. Study Eligibility Criteria | 2. Identification and Selection of Studies | 3. Data Collection and Study Appraisal | 4. Synthesis and Findings | Risk of Bias in the Review |
|---|---|---|---|---|---|
| Cho 200934 | High | Unclear | High | High | High |
| Lin 200929 | High | High | High | High | High |
| Yu 201044 | High | High | High | Unclear | High |
| Sui 201242 | High | High | High | High | High |
| Li 201324 | High | High | High | High | High |
| Shi 201333 | High | High | High | High | High |
| Liao 201425 | High | High | Unclear | Unclear | High |
| Liu 201427 | High | High | Low | High | High |
| Guo 201522 | High | High | Low | High | High |
| Li KX 201526 | High | Low | Low | High | High |
| Li XH 201528 | High | High | Low | Unclear | High |
| Xia 201539 | High | High | Unclear | High | High |
| Xue 201537 | High | High | Low | High | High |
| Yang 201541 | High | High | Unclear | Unclear | High |
| Zhang 201550 | High | High | Low | High | High |
| Chen 201618 | High | High | Unclear | High | High |
| Ruan 201631 | High | High | Unclear | Unclear | High |
| Fang 201721 | High | High | High | High | High |
| Namazi 201730 | High | High | High | High | High |
| Xie 201738 | High | High | High | Low | High |
| Yeh 201743 | High | High | High | High | High |
| Zhang, Tan 201752 | High | High | High | High | High |
| Zhang, Han 201753 | High | High | Low | High | High |
| Cho 201819 | High | High | Low | High | High |
| Kim 201835 | High | Low | Low | High | High |
| Wang 201836 | High | High | Unclear | High | High |
| Zhang YZ 201851 | High | High | Unclear | High | High |
| Zhang KP 201845 | High | High | Unclear | High | High |
| Huang 201923 | High | High | High | High | High |
| Mendona 201920 | High | High | Low | High | High |
| Shan 201915 | High | High | Unclear | High | High |
| Sheng 201932 | High | High | High | High | High |
| Yao 201940 | High | High | Unclear | High | High |
| Chen 202048 | Low | High | Low | Low | High |
| Gao 202049 | High | High | Low | High | High |
| Nie 202046 | High | High | Unclear | High | High |
| Pan 202047 | High | High | Low | High | High |
| Zhong 202014 | Low | Low | Low | High | High |
Flow diagram of study selection.
Quality of the Included Reviews
AMSTAR-2
A summary of the AMSTAR-2 results can be found in . The confidence in the reviews were all rated as critically low except one22 that was rated as low. The major insufficiencies were the lack of registration or publication of protocols prior to commencement of the reviews and justification for excluding individual studies. Thirty14,15,1823,2527,29,30,32,3437,39,40,42,43,4552 of the 38 reviews (78.9%) employed the PICO (population, intervention, control group, and outcome) approach as an organizing framework for establishing study questions (AMSTAR-2 Item 1) but only five reviews14,20,22,32,48 registered or published their protocol before commencement of the review (Item 2). Three reviews justified the selection of study type, eg, RCTs (Item 3).19,23,43 Most reviews (84.2%)14,15,18,19,21,22,2429,3138,4043,4548,5053 included a comprehensive literature search (Item 4), performed study selection in duplicate (78.9%)14,15,1831,3439,42,43,4549,51 (Item 5) and also performed data extractions in duplicate (68.4%)14,15,1823,2630,36,37,40,42,4553 (Item 6). However, none of the reviews provided a complete list of potentially relevant studies with justification for the exclusion of each (Item 7). All but one33 provided characteristic information of their included studies (Item 8) and 2614,15,18,19,22,2528,3133,3537,3941,4551,53 used a satisfactory technique for assessing the risk of bias in individual studies, such as the Cochrane Risk of Bias Tool (Item 9). Only one review reported funding sources of the included studies (Item 10).20 Statistical methods for meta-analysis were appropriate in most reviews (81.6%)14,15,1825,2729,32,34,35,37,4053 (Item 11) but only five reviews24,25,43,45,52 reported the potential impact of risk of bias on the results (Item 12). Although, when reviewers interpreted their results most discussed the impact of risk of bias (71.1%) (Item 13).18,2131,3337,3942,4447,50,52 Exploration of heterogeneity and its impact on the result and clinical recommendations was discussed in 18 reviews (Item 14).15,18,25,2831,3436,39,4349 Publication bias was discussed in 24 reviews15,1825,27,28,34,35,38,4145,4749,52,53 (Item 15) and potential sources of conflict of interest and review funding was noted in 28 reviews14,1823,26,3032,3436,38,40,4253 (Item 16).
ROBIS
The ROBIS tool is divided into four domains. Domain 1, which assesses concerns regarding specification of study eligibility criteria, was only at low risk of bias in two review.14,48 Domain 2 assesses any concerns regarding methods used to identify/select studies. Three14,28,45 achieved a low risk of bias rating overall, one34 was rated as unclear and the remaining 3414,15,1827,2933,3544,4653 were judged to be at a high risk of bias because some eligible studies were likely missing from the review. Domain 3 assesses concerns regarding methods used to collect data and appraise studies. 1414,22,2628,37,40,45,4751,53 of the 38 reviews achieved a low risk of bias, 1115,18,19,25,31,32,35,36,39,41,46 were at unclear risk and 1320,21,23,24,29,30,33,34,38,4244,52 were at high risk of bias because some bias may have been introduced through the data collection or risk of bias assessment (). With regards to domain 4, which assesses concerns regarding the synthesis of results, the majority were rated at high risk of bias because potential bias were ignored or heterogeneity was not accounted.14,15,1924,26,27,29,3140,42,43,4547,4953 Two30,48 was rated as low risk of bias and five18,25,28,41,44 were at unclear risk. The final section of the tool provides a rating of the overall risk of bias of reviews. All the reviews were judged to be at a high risk of bias because one or more of the concerns raised in the other domains was not addressed in the review conclusions and/or reviews did not consider the relevance of the included studies in light of the review question.
Effects of Interventions
Seventeen reviews assessed various acupuncture therapies compared to sham acupuncture or no treatment.14,18,21,26,27,34,35,39,40,42,45,47,48,5053
Five reviews reported significant reduction both in BW and BMI in acupuncture groups.18,34,42,45,47 In terms of BMI, four of the reviews had a high heterogeneity, which may have been due to various acupuncture treatments.18,42,45,47 In one recent review, Pan 2020,47 meta-analysis showed that acupuncture was superior to sham acupuncture in terms of BMI reduction (mean difference [MD] 0.61 kg/m2, 95% confidence interval [CI] 0.86, 0.36, I2 = 64.9%, n = 15) and BW reduction (MD 1.44 kg, 95% CI 2.26, 0.63, I2 = 66.8%, n = 14). Subgroup analysis based on different types of acupuncture therapies including auricular acupuncture and catgut embedding showed similar results to the overall pool of studies. The results were basically consistent with a previous study of Kepei et al in 2018.45
Six reviews showed inconsistent results with reductions in either BW or BMI but not both.39,40,5053 The remaining three reviews failed to show a statistically significant reduction in BW or BMI when acupuncture was compared to sham.26,27,35 However, the number of included RCTs was very small with two reviews26,35 only including one eligible RCT each and the other review27 only including three RCTs.
One study compared acupuncture alone or in combination with lifestyle modification to sham acupuncture or no treatment.21 There was a significant reduction in BMI in the intervention group compared to control. The other three studies showed similar results, with reported reductions in BW and BMI.14,18,48
Auricular Acupoint Stimulation
Five reviews investigated auricular acupoint stimulation compared to sham auricular acupoint stimulation.20,23,33,37,43 Stimulation referred to auricular acupuncture, acupressure, or acupoint taping with seeds. All reviews reported statistically significant meta-analysis results in favour of the auricular acupoint therapies in terms of BW and BMI.
Dongqun et al examined the comparison of auricular points taping and no treatment.37 Only one RCT was included and it showed a favorable effect of auricular acupoint taping in reducing BW and BMI. In another study, results showed no difference in BMI when auricular acupoint stimulation was compared to sham or no treatment.31
Catgut Embedding
Three systematic reviews compared catgut embedding therapy to placebo embedding with variable results.19,22,32 Taipin et al pooled two studies in meta-analysis and reported a favourable effect of intervention on BW reduction (MD 3.10 kg, 95% CI 0.02, 6.0, I2=0).22 In 2018, William et al reported that catgut embedding reduced BW and BMI, however, results had errors as the data was incorrectly pooled.19 Jili et al failed to show a significant effect of catgut embedding on BW or BMI in participants with abdominal obesity.32
Abdominal Acupuncture
One review including one RCT, reported a significant reduction of BMI when abdominal acupuncture was compared to sham abdominal acupuncture in women with obesity (MD 2.01 kg, 95% CI 0.75, 3.27).28
Adverse Events
A total of 27 systematic reviews reported adverse events.14,15,18,19,2123,2532,34,35,37,3943,45,47,48,51 Three reviews stated that no events occurred or were reported in the included studies.15,30,41 Adverse events relating to acupuncture treatments were reported in 24 systematic reviews and events appeared to be mild, tolerable and self-resolving.14,18,19,2123,2529,31,32,34,35,37,39,40,42,43,45,47,48,51 Local reaction to the acupuncture treatments were most common such as redness, pain or discomfort, soreness or swelling, bleeding or bruising.
Discussion
This overview represents a comprehensive review of systematic reviews and meta-analyses on the quality, efficacy and safety of acupuncture clinical trials for people with overweight and obesity. Thirty-eight systematic reviews including over three hundreds clinical trials are identified in this review. Evaluation of the reviews indicated that acupuncture therapies may be effective and safe for weight reduction. However, assessment using AMSTAR-2 and ROBIS indicated that the systematic reviews had methodological shortfalls, and it was difficult to draw a firm conclusion.
The number of people who are affected by overweight and obesity is increasing worldwide, often referred to as a global epidemic.54 The pathogenesis of overweight and obesity is multifaceted and includes a spectrum of environmental, genetic, and epigenetic factors, which all contribute to the disease. Among the environmental factors, an excessive energy intake, a sedentary lifestyle, and circadian rhythm sleep alterations are probably the most important determinants.55 Therefore, reducing daily calorie intake, regulating lifestyle and adapting activity and exercise habits appear to be the basic methods to lose weight. However, the long-term effectiveness of obesity treatments is poor and there are substantial barriers that undermine treatment results. Reasons like lack of recognition of obesity as a chronic condition, time restriction, low socioeconomic status, and a wide range of comorbidities including mental health, sleep, cardiovascular, respiratory, endocrine and digestive disorders should be taken into consideration. The absence of specific obesity training of health professionals, patient attitudes and self-determination as well as availability of obesity treatments are all important barriers.56 Unhealthy weight loss attitudes and short-term weight loss such as vomiting, fasting, using laxatives or diet drugs, has become a concern.5759 Research suggests that non-medical use of prescription drugs for weight loss is relatively common and that this behavior is related to other harmful behaviors with no evidence of effective long-term weight loss.60 Stimulants are the most widely investigated drug with regard to unhealthy weight management practices, because of their potential (and reputation) for expedited weight loss and suppression of appetite.5961
As acupuncture therapies have gained wider recognition throughout the world, acupuncture treatment for weight loss has increased in popularity. In addition to filiform needle acupuncture and electroacupuncture, various types of acupuncture therapies are also applied for losing weight clinically, such as auricular acupuncture, moxibustion, cupping, catgut embedding. According to individual symptom and TCM syndrome, as well as the characteristic of each method, different types of acupuncture therapies would be applied for different patients with obesity. The popularity of acupuncture for weight loss is not without reason. On one hand, acupuncture therapies can not only help to lose weight but also to improve obesity-related problems, such as feeling of heavy body, constipation, menstrual disorder, etc. On the other hand, it is a relatively safe therapy. Adverse events are mainly related to local reaction of the treatment, such as soreness and bruising, which are usually mild and could be self-relief. Whats more, when patients undergo acupuncture treatment, they would be inculcated with healthy knowledge about diet, exercise, lifestyle from their doctor or health manager, which makes them more easier to correct bad life habits and stick to their weight loss program.
The first research about acupuncture therapies for obesity treatment was published in the 1970s.62 It reported that 21 people with obesity achieved weight loss after employing auricular acupuncture treatment lasting from two to six weeks. Following this initial research, many more research studies begun to investigate this emerging area of acupuncture treatment. The potential mechanism of body weight reduction influenced by acupuncture is complex, and it may have several actions on biochemical markers of obesity such as obesity-related peptides (eg, leptin, ghrelin), glucose and lipid metabolism, insulin resistance, and inflammatory markers.63 Therefore, the benefits of acupuncture may be greater than weight loss alone and may include improved metabolism in terms of glucose and lipid levels.64 This prospect is of great significance since obesity is one of the main causes of metabolic disorders such as diabetes, hyperlipidemia, and hypertension.8
There are still some barriers and challenges when it comes to the development and promotion of acupuncture treatment for overweight and obesity. First of all, the lack of standard and precise therapeutic schemes, including acupoint selection, type of acupuncture therapy such as electroacupuncture, manual acupuncture, auricular acupuncture and so on, treatment frequency and duration, all make it difficult to recommend its application more widely. Secondly, effects of acupuncture for losing weight may be affected by factors like age, race, obesity complication, TCM constitution and so on. Therefore, it may be of great significance to discover the advantages group of acupuncture for weight loss. Weight regain is another concern. People with obesity and overweight always go through the cycle of lose weight weight regain. Eventually, they have to compromise and give up their weight loss plan due to various reasons. Although this question was not specifically investigated in this overview or any of the included systematic reviews, it is worth exploring the long-term benefits of acupuncture in future studies. Furthermore, acupuncture is not available in all regions and comes at a cost. Unlike lifestyle interventions such as dieting or exercise, which can be undertaken anytime and anywhere, patients have to attend to a hospital or clinic to receive acupuncture treatments twice to three times a week for some time, which may be a significant barrier to its use.
