World Applied Sciences Journal 7 (4): 531-537, 2009 ISSN 1818-4952 IDOSI Publications, 2009

Physical Training Combined with Dietary Measures and Acupuncture in the Treatment of Adult Obesity. A Comparison of Two Protocols
1

Shehab Mahmoud Abd El-Kader and 2Mamdooh Abdullah Gari

Department of Physical Therapy for Cardiopulmonary Disorders, Geriatrics Faculty of Physical Therapy, Cairo University, Egypt 2 Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, P.O. Box 80324, Jeddah, 21589, Saudi Arabia
1

Abstract: Obesity is a frequent pathology with a multitude of complications; over the last few decades, it has become an increasingly significant public health concern in both developed and developing countries. The aim of our work was to compare two types of treatment protocols to determine the efficiency of physical training and dietary measures with acupuncture or electroacupuncture in management of obese females. Forty obese females participated in the study and were included in two equal groups. The first group (A) received physical training combined with dietary measures and acupuncture. The second group (B) received physical training combined with dietary measures and electroacupuncture. The program consisted of three sessions per week for three months. There was a significant decrease in Body Mass Index (BMI), Waist Circumference (WC), Hip Circumference (HC), Waist Hip Ratio (WHR), blood Leptin, Total Cholesterol (TC), Low Density Lipoprotein Cholesterol (LDL-c) and Triglycerides (TG) and increase in High Density Lipoprotein Cholesterol HDL-c in both groups after treatments, but the changes in group (B) were greater than in group (A). However, there was no significant difference between mean levels of the investigated parameters in group (B) and group (A) posttherapy. So, physical training and dietary measures with electroacupuncture can be used as methods of choice for management of obese females. Key words: Obesity Physical Training Dietary Measures Acupuncture Electroacupuncture

INTRODUCTION The prevalence of overweight and obese individuals is increasing at an alarming rate and obesity has become one of the most important avoidable and independent risk factors for morbidity and mortality [ 1]. Leptin is a protein that exerts important effects on the regulation of food intake and energy expenditure by interacting with the leptin receptors in the brain and in many other tissues. In addition, leptin functions as a neuroendocrine hormone and regulates many metabolic activities [2]. Weight management program must include dietary adjustment, increase physical activity and behavior modifications. Nutrition modification should take into account the diets energy content, composition and suitability for individual patient [3].

European standards for energy restricted diets have been established, leaving little flexibility for change. Three categories exist (i.e., very low-calories diets [450 to 800 kcalorie], low-calorie diets [800 to 1200 kcalorie] and meal replacements [200 to 400 kcalorie] [4]. Increased exercise is associated with a lower waisthip ratio (WHR), percentage of body fat and high-density lipoprotein cholesterol level (HDL-C). Higher levels of high-density lipoprotein cholesterol are generally associated with lower levels of triglycerides. Vigorous exercise in the premenopausal women may promote a more favorable lipid profile, even in the presence of increased body fat [5]. Acupuncture can provide good therapeutic effects for simple obesity, as after twenty sessions the body weight, waistline and the serum total cholesterol (TC), the fasting triglyceride (TG) and low-density lipoprotein

Corresponding Authors: Dr. Shehab Mahmoud Abd El-Kader, Department of Physical Therapy, Faculty of Applied Medical Sciences, King Abdulaziz University, P.O. Box 80324, Jeddah, 21589, Saudi Arabia

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(LDL) were significantly changed[6]. On the other hand, electroacupuncture was found to reduce body mass, decrease fatty tissues content and normalization of blood serum lipids [7]. Combination of a laser acupuncture and low-caloric is characterized by higher efficiency than a low caloricdiet alone in lowering body weight, body mass index, waist/hip ratio [8]. The aim of our work was to compare two types of treatment protocols to determine the efficiency of physical training and dietary measures with acupuncture or electroacupuncture in management of obese females. MATERIALS AND METHODS Subjects: Forty obese women with total body obesity (body mass index (BMI) = 30 Kg/m2, free from respiratory, kidney, liver, metabolic and neurological disorders. Subjects were not smokers and not receiving drugs. Their age ranged from 20 to 40 years. The subjects were included into 2 equal groups; group (A) received physical training combined with dietary measures and acupuncture. The second group (B) received Physical training combined with dietary measures and electroacupuncture. informed consent was obtained from all participants. All participants were free to withdraw from the study at any time. If any adverse effects had occurred, the experiment would have been stopped, with this being announced to the Human Subjects Review Board. However, no adverse effects occurred and so the data of all the participants were available for analysis. Methods Evaluated Parameters Chemical Analysis: Blood sample after fasting for 12 hours was taken from each women in clean tubes containing few mg of K2EDTA, centrifuged and plasma was separated and stored frozen at-20 used for estimation of plasma leptin level by immunoradimetric assay (IRMA), plasma lipid profile includes Triglycerides, Total cholesterol, HDL and LDL. Evaluation of Anthropometric Parameters: All measurements were performed at pretreatment and after three months at the end of the study. The participants were measured whilst wearing their undergarments and hospital gowns. Height was measured with a digital stadiometer to the nearest 0.1 cm (JENIX DS 102, Dongsang, South Korea). Body weight was measured on a calibrated balance scale to the nearest 0.1 kg 532

(HC4211, Cas Korea, South Korea) and BMI was calculated as Body weight/Height2. Waist circumference (WC) was measured midway between the lateral lower rib margin and the iliac crest. The hip circumference (HC) was measured at the levels of the major trochanters through the pubic symphysis to the nearest 0.1 cm. Obesity Management Methods The Prescribed Low Calorie Diet: The interview-based food survey was performed for all patients by dieticians to specify previous food habits and possible anomalies in dietary behavior. The prescribed low calorie diet was balanced, with 15% as protein, 30 to 35% as fat and 50 to 55% as carbohydrate, on average, in order to provide about 1000 calories daily for two months for whole participants in this study. The prescribed diet included the breakfast consisted of 2 boiled eggs (80.calorie), 50 gm cheese (100 calorie) and one bread (105 calorie), where the lunch consisted of 2 pieces of boiled meat 100gm (240 calorie) or chicken (300), 500 gram salad (105 calorie), 300 gram boiled vegetables (110 calorie) 100 gram and banana (100 calorie), However, the dinner consisted of 200 gram light milk (120 calorie). We checked that food was eaten as three daily meals and we emphasized the need to have a substantial breakfast. The two groups underwent an identical dietary monitoring programme, with an initial consultation, a check-up in the middle of the programme and another during the final sessions by a dietician who was blinded to the type of the programme that the subject had been following. The Physical Training Programme: The aerobic treadmill-based training programme (PRECOR 9.1/ 9.2, China) was set to 60% of the maximum heart rate (HRmax) achieved in a reference ST performed according to a modified Bruce protocol. This rate was defined as the training heart rate (THR).After an initial, 5-minute warm-up phase performed on the treadmill at a low load, each endurance training session lasted 30 minutes and ended with 5-minute recovery and relaxation phase. All patients performed three weekly sessions (i.e. a total of 36 sessions per patient over a 3-month period. Acupuncture: The obese females were treated by pressing stainless steel needles (Dong-Bang Medical, South Korea) in one ear, the needles were changed every 7 days for sterilization and to prevent adaptation, the auricular points were shenman, stomach, endocrine,

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duodenum, hunger and spleen points. Also subjects were treated by pressing needles in ``meridian acupuncture body points used in reduction of body weight. The meridian body acupuncture points were stomach ST 36, large intestine 4, lungs 5 and stomach 25. Each session was continued for 30 minutes; 3 sessions / week for 3 months. Where the auricle needle was 0.5 inches in length and 2.7 mm in diameter and body needles which varied in length, between 2.0 inches to 3.0 inches in length and 5.8 mm in diameter to 76 mm. Electroacupuncture: An electric stimulator (model III Acupuncture Anesthesia, Tokki, Japan) to provide simulation for the acupuncture needle. The standardized acupuncture points were chosen according to the theory of Chinese medicine and clinical experience. Eight acupuncture points on the abdomen were selected: CV 6 (Chi Hai), CV 10 (Hsia Wan), CV 12 (Ching Wan), CV 13 (Shang Wan), left and right side of SP 15 (Ta Heng) and both side of ST 25 (Tien Shu). Stainless-steel acupuncture needles were inserted to a depth of approximately 2.5 cm after skin sterilization. Each needle was rotated back and forth until the subject experienced the sensation of De-Qi. The acupuncture needle was then connected to an electric stimulator that provided simulation for 50 min with 15-mA, 0.05-ms square waves at a rate of 3 Hertz. All subjects were asked to receive three treatments per week for a total of 3 weeks for 3 months. Statistical Analysis: The mean values of BMI, WC, HC, WHR, blood Leptin, TC, LDL-c, HDL-c and TG obtained

before and after three months in both groups were compared using paired "t" test. Independent "t" test was used for the comparison between the two groups (P<0.05). RESULTS Forty obese females participated in the study and were included in two equal groups. The first group (A) received physical training combined with dietary measures and acupuncture. The second group (B) received physical training combined with dietary measures and electroacupuncture in order to compare two types of treatment protocols to determine the efficiency of physical training and dietary measures with acupuncture or electroacupuncture in management of obese females. Measurements of BMI, WC, HC, WHR, blood Leptin, TC, LDL-c, HDL-c and TG obtained before and after three months in both groups were compared using paired "t" test. The mean BMI, WC, HC, WHR, blood Leptin, TC, LDL-c and TG values were significantly lower statistically, where the mean HDL-c values were significantly higher statistically in both groups after treatments, but the changes in group (B) were greater than in group (A) (Tables 1, 2, 3 and 4). There were no statistically significant differences between mean levels of the investigated parameters in group (A) and group (B) after treatment (Tables 5 and 6). These results support the use of electroacupuncture in addition to the physical training and diet measures in clinical management of obese females.
P value 0.008 0.004 0.006 0.011

Table 1: Comparison of group (A) anthropometric parameters before and after treatment Parameters MeanSD T-test BMI (Kg/m2) Before 35.996.99 7.93 After 33.146.59 WC (cm) Before 108.114.55 10.27 After 97.0513.45 HC (cm) Before 118.414.727 8.66 After 108.213.181 WHR Before 0.91250.049 2.33 After 0.89120.063 BMI= Body Mass index WC = waist circumference HC = Hip circumference WHR = waist Hip Ratio Table 2: Comparison of group (A) blood lipid profile and Leptin before and after treatment Parameters MeanSD T-test Leptin Ng/ml Before 39.647.94 12.681 After 36.687.46 TC (mg/dl) Before 197.3523.39 10.288 After 166.4527.01 HDLc (mg/dl) Before 35.852.28 8.373 After 37.702.15 LDLc (mg/dl) Before 135.224.96 8.647 After 119.623.84 TG (mg/dl) Before 158.0523.05 12.269 After 125.8025.63 TC: Total cholesterol HDL-c: High density lipoprotein cholesterol LDL-c: Low density lipoprotein cholesterol TG: Triglyceride

P value 0.005 0.001 0.008 0.002 0.001

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Table 3: Comparison of group (B) anthropometric parameters before and after treatment Parameters BMI (Kg/m2) WC (cm) HC (cm) WHR BMI= Body Mass index Before After Before After Before After Before After WC = waist circumference MeanSD 37.5910.407 34.0810.144 108.515.97 93.317.031 120.517.16 108.117.15 0.90630.061 0.8620.076 HC = Hip circumference WHR = waist Hip Ratio 4.259 0.009 11.044 0.002 13.544 0.004 T-test 13.034 P value 0.000

Table 4: Comparison of group (B) blood lipid profile and Leptin before and after treatment Parameters Leptin Ng/ml TC (mg/dl) HDLc (mg/dl) LDLc (mg/dl) TG (mg/dl) TC: Total cholesterol; Before After Before After Before After Before After Before After MeanSD 41.5011.51 37.6611.21 201.616.93 167.9522.65 33.901.48 36.41.06 134.514.27 115.016.44 181.325.44 141.9524.9 LDL-c: Low density lipoprotein cholesterol; TG: Triglyceride 13.352 0.005 7.541 0.003 8.238 0.006 10.671 0.001 T-test 13.241 P value 0.003

HDL-c: High density lipoprotein cholesterol

Table 5: Comparison of group (A) and group (B) anthropometric parameters after treatment Parameters BMI (Kg/m2) WC (cm) HC (cm) WHR BMI= Body Mass index Group (A) Group (B) Group (A) Group (B) Group (A) Group (B) Group (A) Group (B) WC = waist circumference MeanSD 33.146.59 34.0810.144 97.0513.45 93.3017.031 108.213.181 108.117.15 0.8910.63 0.8620.76 HC = Hip circumference WHR = waist Hip Ratio 1.315 0.196 0.021 0.984 0.765 0.449 T-test 0.346 P value 0.731

Table 6: Comparison of group (A) and group (B) blood lipid profile and Leptin after treatment Parameters Leptin Ng/ml TC (mg/dl) HDLc (mg/dl) LDLc (mg/dl) TG (mg/dl) TC: Total cholesterol Group (A) Group (B) Group (A) Group (B) Group (A) Group (B) Group (A) Group (B) Group (A) Group (B) MeanSD 36.687.46 37.6611.21 166.427.01 167.922.65 37.72.15 36.41.06 119.623.84 11516.44 125.825.63 141.924.9 LDL-c: Low density lipoprotein cholesterol TG: Triglyceride 2.02 0.07 0.710 0.482 2.165 0.067 0.190 0.85 T-test 0.325 P value 0.747

HDL-c: High density lipoprotein cholesterol

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DISCUSSION The aim of the present study was to analyze the changes in anthropometric measurements and plasma leptin as well as plasma lipid profile in response to physical training and dietary measures with acupuncture or electroacupuncture in clinical management of obese females. The results of the present study concerning BMI showed that there was a significant reduction in BMI of group (A) received physical training and dietary measures with acupuncture and group (B) received physical training and dietary measures with electroacupuncture, while the difference between both groups after therapy was not a significant. Regulation of body mass index was reported in obese subjects received acupuncture therapy [9]. However there was a higher efficiency of low caloric diet and acupuncture than low caloric diet only in lowering of BMI and body weight of obese persons [10]. There was a significant correlation between leptin values and BMI [7]. The essential components of a weight loss or weight management program include: calorie reduction of 300-500 calories per day, appropriate exercise, variety in food choices, increased consumption of grains, fruits and vegetables and reduction of fat to no more than 30% of daily calories [11].Application of strength exercises displayed an increase in lean mass and a greater decrease in fatty mass. These observations emphasize the beneficial effect of strength exercises in the management of obesity [8]. The results of the present study concerning WC, HC and WHR showed that there was a significant reduction in both groups and the decrease was greater in group (B) than in group A, but the difference between group (A) and group (B) after treatment was not significant. Stimulation of mouth, Shenman, stomach, hunger and spleen auricular points for 2 to 6 weeks resulted in weight loss in these patients varied from 2-16 pounds [12]. Waist and hip circumference, lipid metabolism and the levels of cyclic adenosine monophosphate (cAMP) can be regulated by acupuncture [13] as acupuncture stimulates the auricular branch of vagus nerve and raises serotonin levels, both of which have been shown to increase tone in the smooth muscles of the stomach, thus suppressing the appetite which leads to weight loss in overweight patients[14]. Abdominal electroacupuncture stimulation reduced BW, WC and HC by 5.3%, 4.6% and 4.0%, respectively. Under the premise that WC is related to the subcutaneous 535

fat tissue of the abdomen, abdominal electroacupuncture might help redistribute or lyse abdominal fat tissue directly and also other body adipose tissue [15]. Bilateral auricular acupuncture stimulation clearly modulates feeding-related hypothalamic neuronal activity of experimental (both hypothalamic and dietary) obese rats [16]. Treatment by pellet pressure on auricular acupoint plus body acupuncture for 3 months was superior in reduction body weight and decrease in appetite than obese treated by diet in subjects with simple obesity [17]. The results of the current study concerning plasma leptin level showed that there was a significant reduction in both groups and the decrease was greater in group B than group A, but the difference between the mean plasma leptin level in the 2 groups after therapy was not a significant. Leptin signaling to brain stem hypothalamic pathways potentially increases the brain's motor and autonomic responses to satiety signals, leading to smaller individual meals, reduce cumulative food intake and a lowers body weight [1]. Leptin is a regulator of food intake and is increased in plasma of subjects with low energy expenditure and high adiposity[18]. Physical activity may be a significant determinant of plasma leptin concentrations in men. Increasing physical activity was associated with lower plasma leptin concentrations even after adjusting for BMI. Physical activity may lower leptin concentrations not only due to the decreased body fat mass, but potentially through an increase in leptin sensitivity [19]. The results of this study concerning TC showed that there was a significant reduction in both groups and the decrease was greater in group (B) than group (A), but the difference in the total cholesterol level between the 2 groups after therapy was not a significant. Auricular acupuncture plus body acupuncture reduce TG and TC levels in overweight and obese subjects [20]. Acupuncture has a good regulation effect on lipid metabolism and plasma cycling adenosine monophosphate. Auricular acupuncture plus body acupuncture decreased total blood cholesterol.They attributed the effect of acupuncture to its beneficial effect on hypothalamus-pituitary axis. cAMP in adipose tissue and in liver is produced by the membraneous enzyme adenylate cyclase that acts on ATP producing cAMP and liberating pyrophosphate. cAMP is involved in the activation of phosphorylase helping glycogenolysis and on lipase enzyme helping lipolysis [21].

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The results of the study concerning HDL-c showed that there was a significant increase in both groups and the increase was greater in group B than group A and the difference between the two groups after treatments was a significant. Exercise resulted in an increase in HDL-c (10.7%) and a concomitant fall in triglyceride (-25%) and total cholesterol (-3.5%) [22]. Where, exercise-induced increases in HDL-c and decreases in triglyceride are similar in hyper-and normo-cholesterolemic men and may be mediated, at least in part, by an increase in lipoprotein lipase activity [23] The results of the current study concerning LDL-c and TG showed that there was a significant decrease in both groups and the decrease was greater in group B than group (A) and the difference between the two groups was not a significant. Energy restriction resulting in even modest weight loss suppresses endogenous cholesterol synthesis which leads to a decline in circulating lipid concentrations and increased insulin sensitivity that contributes in improving lipoprotein profile after treatment of obesity [24-25]. Electroacupuncture can reduce the body weight by 4.5%, with a parallel reduction in the leptin level, total cholesterol, triglyceride and LDL cholesterol by increasing the beta-endorphin level which stimulates lipolysis [26]. The results of the present study provide the recommendation for future researches on a large sample size in order to explore the details differences between the acupuncture and the electroacupuncture as the no significance difference between the two treatment protocols followed in this study may be due to the small sample size in this study. CONCLUSION The results from this study provide a foundation for the exploration of a nonpharmacological therapy for reducing obesity-related parameters as a result of physical training combined with dietary measures and electroacupuncture. ACKNOWLEDGEMENTS The authors thank Prof. Dr. Nagwa M. Badr for her skilful assistance during clamp procedures. We are grateful for the cooperation and support of all patients who participated in this study. 536

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