Cermin Dunia Kedokteran

TINJAUAN KEPUSTAKAAN

Mechanism of Acupuncture

in Treating Obesity

Manius Marinusa & Rudi Kastono

KSMF Akupunktur RSUPN Dr Cipto Mangunkusumo, Jakarta

The efficacy of acupuncture in treating obesity has been

widely known and proved in several clinical trials with signi-

ficant results. Many weight reduction programs have included

acupuncture in their programs. However, if asked about the

mechanisms of acupuncture in weight reduction, many acu-

puncturists still find it hard to explain scientifically. There are

still controversies over the efficacy and mechanisms of acu-

puncture in weight reduction. A nutritionist stated that acu-

puncture just makes it easier to diet and has no actual control

over body's fat

(1)

. A scientific explanation of the mechanisms of

acupuncture could perhaps clear up these controversies.

Obesity is the most prevalent, chronic, medical condition in

our society and is directly or indirectly associated with a wide

variety of diseases that collectively account for 15 - 20% of the

mortality rate. In developed countries approximately 35% of the

adult population is obese, and there are indications that the preva-

lence is increasing. Jellife and Jellife found that, in Britain, young

and middle-aged men weighed 15 pounds heavier than 30 years

before, with slight increase in height

(2)

Obesity means an excess of body fat. Overweight means the

body weight is in excess of some arbitrary standard. In most

studies of prevalence, overweight is defined as 10% above the

ideal body weight given in standard tables and obesity is defined

as 20% above the ideal body weight. While being obese is being

overweight, being overweight does not always mean someone

has excess fat. The overweight may be due to muscle or other

body constituents. Thus it is necessary to estimate the body fat

not the weight if possible. Determining the Body Mass Index

(BMI), obesity is defined as having BMI over 30. Body Mass

Index equals weight devided by height squared (BMI = W/H

Measuring the triceps skinfold using calipers, obesity is defined

as having triceps skinfold meansurement greater than one stan-

dard deviation from the mean, or if the measurement is greater

than 15 mm for men and 25 for women.

Obesity is classified anatomically into normocellular and

normocellular

if their fat cells number is normal, and hypercellular if their fat

cells number is increased. Fat cells increase in number during

childhood and teenage. M abnormal increase in fat cells during

childhood and adolescence predisposes to obesity in adulthood

which is very resistant to treatment. Juvenile onset obesity can

be classified into constitutional or genetic which starts early in

infancy and symptomatic obesity which is a symptom of an

underlying physical or emotional disorder. The latter may start

any time in childhood and there may be precipitating factors.

Obesity caused by emotional factors in childhood is also called

developmental obesity in contrast to the obesity triggered by

obesity.

hypercellular type. Obese subjects are classified as

emotional factors in adulthood which is termed reactive

Based on pathogenesis, obesity can be classified into

regulatory obesity which is associated with disorder of the

mechanisms regulating food intake, and metabolic obesity in

which there is an inborn or acquired error in metabolism. This

last classification is useful for research and treatment whereas

the former are useful for prevention of obesity.

Sun et al, got a 88,9% effective rate treating obesity with

acupuncture,

(4)

Liang and Chen had a 84,8% effective rate using

acupuncture,

(6)

Huang obtained a 76,9% effective rate using ear

pressing combined with body needling,

(7)

Lau et al got a 74%

result using auri acupuncture.

(8)

The long term effect of acu-

puncture was satisfactory after one course of treatment but

improved after two or three courses of treatment. Liu et al re-

ported that evaluation one year after the last treatment gave a

74,4% effective rate for one coui 91,7% for two courses and

100% for three courses of treatment.

(9)

MECHANISMS OF ACUPUNCTURE IN TREATING

OBESITY REGULATING FOOD AND ENERGY INTAKE

One of the pathogenesa of obesity is disorder in the mecha-

Cermin Dunia Kedokteran No. 123, 1999

nisms regulating food intake, producing an increase in appetite

and excess food intake.Acupuncture can treat this disorder in

several ways:

1. Decreasing appetite by interfering with the serotonergic

pathway in the brain.

2. Abatement of appetite via the vagus nerve in the conchae

(auricular acupuncture).

3. Lessening nutrition intake by reducing hyperfunctioned gas-

tric digestion and intestinal absoption.

Decreasing appetite by interfering with the serotonergic

pathway in the brain

Anand and Brobeck postulated that food intake is controlled

by regulatory mechanisms in the veñtromedial nucleus and lat-

eral nucleus of the hypothalamus. It is known as the dual center

hypothesis. According to this hypothesis the ventromedial serves

as a satiety center and acts as an inhibitor of the feeding center

located in lateral hypophysis.

2,10

Experiment in animal have pro-

duced results predicated by this hypothesis. Lesions in ventro-

medial hypothalamus made the animal hyperphagic, whereas

lesions in lateral hypothalamus caused the animal to be aphagic.

Injections of procain into the ventromedial area increased food

intake. The Opposite results were produced by electrical stimu-

lations of the lateral hypothalamus. At present amine theory is

better received.

Amine theory postulates that lesions in the ventromedial and

lateral hypothalamus cause the observed by interrupting

amine pathways rather than by a local effect on the ventromedial

or lateral hypothalamus. It states that satiety is controlled by the

ventral noradrenergic system and the motivational aspects of food

seeking behaviour are modulated by the nigrostriatal dopamin-

ergic system.

The nigrostriatal dopaminergic system which has its origin

the substantia nigra and terminates in the neostriatum,

modulates motivation to seek food through the involvement of

dopamlne, gamma-aminobutyric acid (GABA) and serotonin. If

the content of doparnine raises, there is less motivation to search

for food. `The person appears to be satisfied. If the content of the

dopamin lowers, the person feels hungry and begin to seek

food. The content of the dopamin here is checked by gamma -

amino butiric acid (GABA) so that there is a constant level that

can maintain the normal appetite. The satiety feeling after

eating is provoked by the autonomic afferent input from the

digestive tract and viscera to the hypothalamus. This input

activates serotonergic pathway in the hypothalamus to secrete

serotonin. The release of serotonin begins a series of reactions

ending with the increase in dopamin secretion.

The stimulations of the point Cu San U (III, 36) in rabbits

produced excitation of the lateral hipothalamus with the effect

of inhibition of the hyperfuncti6n of the stomach.

(11)

Acupuncture activates the descending and ascending

serotonergic pathways via the anterolateral tract. When acupunc-

ture stimulation, particularly of high frequency, low intensity

electrical stimulation (50-200 Hertz), is applied at correct points,

neural impulses are received in the dorsal horn of the spinal cord

via the type II and type III muscle afferent nerves (small diameter

myelinated afferents). These impulses are conveyed to a variety

of fibers in the anterolateral tract, several of which projects to

the mid brain to, influence that descending and ascending

serotonergic pathways.

The raphe magnus in the brainstem

contains most of the serotonin cells in the brain. These cells have

axons in the ascending tract which projects to the midbrain and

forebrain besides the descending dorsolateral tract which plays

important role in acupuncture analgesia. These impulses in the

anterolateral tract also stimulate excitatory neurons in the

hypothalamus to release serotonin. The increase content in the

midbrain enhances the activity of the nigrostriatal dopaminer-

gic pathway thus produces decreased appetite.

The system works in a cascade pathway. The serotonin re-

leased from neurons in the hypothalamus activates the methionin-

enkephalin which is released in the ventral tegmental region. Here

it inhibits the release of GABA from the substantia nigra. The

inhibition of GABA increase the supply of dopamine in the

ventral tegmentum. This in turn increase the direct effect of

dopamine on the hippocampus through the amygdala which is

the termination of the mesolimbic dopaminergic system The

effect of dopamine increase in the nucleus accumbens and hip-

pocampus is a feeling of satiety and loss of motivation to seek

food. The amygdala and the hippocampus play important roles

in the cascade system. It was found by Fonberg (1961) and Mor-

gan (1960) that, in cat, stimulation of the basal lateral part of the

amygdala inhibits food intake and destruction of the amygdala

increases food intake.

Perhaps there is no such thing as feeding center or hunger

center in the lateral hypothalamus. What exist are the dopamine

projections to the forebrain or the medial forebrain bundle. In

fact this system does not only work for food seeking motivation,

it controls other motivation as well, such as water and sex. Le-

sions to the bundle not only depressed food seeking behaviour

but caused sensory neglect to all kind of stimuli.

Is the high frequency, low intensity electrical stimulation

the only way to produce reduction of appetite by acupuncture?

What about the manual twirling of the needle and the low

frequency electrical acupuncture stimulation? Can these and

other modalities such as laser or ultrasound as well as the

application of press needle lower the appetite? Hari discovered

that the application of low frequency (2 - 15 hz)

electroacupuncture stimulation on the points Cu San U (III,36)

and San Yin Ciao (IV,6) on the hind leg of rabbits for 30 minutes

produced a significant increase in the level of methionin-enkepha-

lin in the hypothalamus.

This increase may be due to the direct

effect on methionin-enkephalin or also through serotonin but the

fact tells us that low frequency electroacupuncture stimulation is

also able to activate the cascade system leading to the reduction

of appetite. But it is not certain whether the effect is as good as

that of the serotonin pathway. It was found out that lowering

the content of intracerebral serotonin sharply decreased the an-

algesia producted by enkephalin.

The lateral feeding center or the neurohumoral pathways

that are responsible for food seeking behavior are active chroni-

cally where as the satiety is glucostatically active.

Consequently

the effect of acupuncture on appetite is not just restricted to the

duration on stimulation.

Cermin Dunia Kedokteran No. 123, 1999 13

Abatement of appetite via the vagus nerve in the conchae

(Auricular acupuncture)

The external ear or auricle is supplied abundantly with nerve

endings, derived from the trigeminal, facial, glossopharyngeus,

and vagus nerves.

The conchae is especially supplied by the

auricular branch of the vagus nerve. It arises from the superior

(jugular) ganglion and enters the temporal bone through a fora-

men in the lateral wall of the jugular fossa, traverses the tiny

mastoid canaliculi, and emerges from the skull through the tym-

panomastoid fissure. The somatosensoric impulses from the sur-

face of the ear canal and the conchae are transmitted by this branch

of vagus nerve.

If a stimulation, be it mechanical, electrical or laser is pro-

duced on the conchae, neuronal impulses are sent to the central

nervous system by way of the vagus. These impulses can

interfere with the impulses bearing appetite signal coming from

the gastrointestinal tract because of their common neuronal

pathway to brain.

A hungry (empty) or full sensation is

conveyed through the viscerosensoric pathway of the vagus.

The impulses are received by nucleus solitarius and projected to

the reticular substance of the brainstem. Then via the posterior

ventral thalamic nucleus the impulses are projected to the cere-

bral cortex.

The appetite signal may be blocked to a certain

degree by the sensory impulses from the auricular branch of the

vagus nerve and the hunger is less felt and the desire for food

decreases. The stimulation produces nerve fatigue. The efficacy

of the continuous stimulation is less after a period of two weeks.

A rest of 7-10 days should be given in order to obtain the

previous result.

Lowering Intake by reducing byperfunctioned gastric

diges- tion and Intestinal absorption

The movement of the stomach and intestines and the rate

of intestinal absorption, all determine the volume of nutrients the

body gets. Hyperfunctioned gastric digestion and intestinal

absorption provide more energy intake which if not utilised is

turned into fatty tissue. Besides, the fast rate of stomach empty-

ing time causes the individue to feel hungry faster and more of-

ten. This with the better energy intake factor lead to overweight

and obesity. The movement of the stomach and intestine as well

as the secretory function are regulated by automatic of vegeta-

tive nervous system which, based on the opposing but comple-

mentary functions, is classified into two structures: the sympa-

thetic and parasympathetic nervous system. The peristalsis and

the secretory are enhanced by the parasympathetic where as the

sympathetic has the opposite effect.

The parasympathetic nervous system for the gastrointesti-

nal tract is supplied by the vagus nerve.

(17)

The branch for the

stomach is visceromototric and secretomotric, where as for the

pyloric sphincter it has inhibitory function. The branch for the

intestines is visceromotoric and secretomotoric for mucous glands

smooth muscles of intestine, jejunum, caecum, ascending colon

and most of the transverse colon. It has inhibitory function on

ileocaecal sphincter. The myelinated preganglionic fibers of the

sympathetic nerves which, innervate the digestive tract, leave

the spinal cord at the 5th to the 9th thoracal segments following

the anterior ramus and pass through the para ventebral ganglia to

join the greater splanchnic nerve. It then synapses in the celiac

ganglion. The unmyelinated postganglionic fibers then go to in-

nervate the stomach and the intestines. The activation of the sym-

pathetic nerves has effects on the digestive tract opposite to those

of the parasympathetic. Together they maintain a tonic level of

both which is termed autonomic tone. Because of the tone the

activities of the intestines and glands can be increased either by

an increase in parasympathetic input or by a decrease in

sympathetic input or vice versa.

(14,17)

In fact it is like the Yin

Yang phenomenon.

Most of the people with obesity has parasympathetic input

higher than normal people and sympathetic input lower than nor-

mal people. in these people the digestive function is overactivated

which can be seen from several parameters : the secretion of

saliva, the activity of the salivary amylase and the acetylcholine

esterase, the content of pepsinogen and blood amylase is higher

than normal people. The excretion of d-xylose, which

reflects the absorption function of the intestine, is also higher

than persons that are not obese, whereas the content of

norepinephrine is lower than normal than normal subjects. The

norepinephrine are the neurotransmitters working in the

neuromuscular synapses of sympathetic nerves. The post-

ganglionic synapses of the parasympathetic use acetycholine as

transmitter. The oral prostaglandin E

level is also lower than in

normal subjects. This substance can relax gastric muscles, dilate

the gastric antrum, delay of sympathetic nerves. The activity of

the sympathetic nerves and the parasympathetic nerves must be

in equilibrium. The equilibrium index of the vegetative nervous

system (Y) can be calculated from Liang's regression equation:

Y= -28-O.194X

+ 0.03 1 X

+ 0.025 X

- 0.792 X

-0.131 X

0.649 X

. The Y in obese subjects is often lower than that in

normal subjects.

(22)

After receiving acupuncture treatments with points tailored

to diagnoses according to syndrome differentation, Liu et al, in

several clinical studies found that the above parameters such as

salivary amylase, blood amylase, pepsinogen, acetylcholone

esterase and the xylose excretion rate in urine were lower

whereas the norepinephrine, oral prostaglandin E

and Y value

raised.These facts tell us that acupuncture can balance the previ-

ously imbalanced automatic tone. Perhaps it is through the

automatic nervous systems that acupuncture exerts many of its

actions which sometimes seem to be contradictory such as

lowering the blood pressure in one person but raising the blood

pressure in another.

The question is how acupuncture regulates the autonomic

tone? Needle insertion causes tissue damage and repair reaction

which produce bradykinin. Bradykinin excites A-delta and C

unmyelinated fibers in the skin. This primary afferent

depolarization produces impulses that are conducted via the tract

of Lissauer and dorsolateral funiculus in the spinal cord. The

dorsal root potential triggers a reflex which is antidromically

fired through the sympathetic C fibers to viscera. This

Cermin Dunia Kedokteran No. 123, 1999

viscerosomatic reflex affect the entire automatic the

sympathetic C fibers to viscera. This viscerosomatic reflex

affect the entire autonomic system. Both sympathetic and

parasympathetic responses can be provoked through somatic

stimulation induced dorsal root potential that can be produced

by body and ear acupuncture stimulation. The same impulse

crosses the contralateral side to periaqueductal gray.There are

fibers that connect the periaqueductal gray to the intralaminar

nuclei of the hypothalamus.

Hypothalamus is the main regulator of the autonomic

nervous system. In the periventricular nuclei there are neurons

that project axons to the parasympathetic motor nuclei in the

brainstem ad the sympathetic motor nude in the spinal cord. So

acupuncture can treat obesity through its action on the autonomic

nervous system.

Increasing energy expenditure

Increasing basal metabolic rate (BMR)

Energy is expended in 3 major ways : basal metabolism,

specific dynamic action of food, and physical activity. The en-

ergy expense can be obtained from food ingested or from stored

energy, primarily adipose tissue. Factors known to alter basal

metabolic rate include age, sex,temperature, drugs, hormones,

and nutritional status. Men have higher BMR than women. BMR

decreases with age thus the percentage of fat content increases

slightly with age. Changes of body temperature also affect BMR.

One degree raise in body temperature either internally or exter-

nally generated, raises the BMR by 12%. Thyroid hormone,

growth hormone, glucagon and epinephrine increase BMR and

are termed calorigenic.

(2)

After an injection of tri-iodothyronine

(T3) into a hypothyroid patient, the metabolic rate is not imme-

diately affected. The peak activity occurs ito 5 days later. With

thyroxine the delay is even longer, about 8 to 18 days later. The

delays imply that it is through an indirect action, protein synthe-

sis, that the metabolic rate is affected.

A recent theory states that thyroid hormone may increase

the rate of ionic transport across cell membranes. Since perhaps

half of the basal metabolism is involved in maintaining ion equi-

librium between intracellular compartments, an increase in ionic

transport across cells means increase in basal metabolic rate. ATP

ase is the above ionic transport and to produce heat in the body.

At present it is thought that the enhancing effect of thyroxin on

ATP-ase level and BMR are lower in some obese subjects

compared to normal subjects. It was found by Liu et al that

acupuncture increased the thyroxin content in obese patients

treated by acupuncture.

Thus it is suggested that

acupuncture might increase BMR by enhancing the function

of the hypothalamus-pituitary-thyroid axis and therefore

stimulate the secretion of thyroxin which then raises the activity

of ATP-ase.

The activation of the neurons in hypothalamus by acupunc-

ture stimulation has been explained above. In the periventricular

nuclei there are endocrine neurons that secrete thyrotropin

releasing hormone (TRH) which is released and transported to

the anterior pituitary through portal blood supply. Here it causes

the cells to release thyroid stimulating hormone (TSH) to the

blood circulation. In its target organ TSH stimulates the thyroid

gland to produce thyroxin and tri-iodothyronine.

Growth hormone is also calorigenic. It produces a small in-

crease in BMR. Growth hormone concentrations are lower than

normal controls in obese patients. It was demonstrated that 5mg.

per day of growth hormone given to obese patients for 8 days

produced an increase in oxygen consumption of 10%. Liu et al

found that in obese patients successfully treated with acupunc-

ture the levels of growth hormone are raised whereas in the failed

group the levels are lower. 24 The growth hormone is secreted by

the anterior pituitary by the control of the growth-hormone-re-

leasing hormone (GRH) also produced in the periventricular

nuclei of the hypothalamus.

In small doses, epinephrine is calorigenic as well. In the.

body epinephrine is produced by the adrenal medulla which gets

direct innervation from the sympathetic have. If the activity of

the sympathetic is high more epinephire is produced. Acupunc-

ture can produce higher BMR and more lipolysis by raising the

sympathetic tone.

The activity of the ATP-ase is reduced by hypercholester-

olemia. Acupuncture can also raise the activity of ATP-ase by

altering lipid composition in the cell membrane which is influ-

enced by high cholestereolemia.

Treating hyperinsulinism

Hypercholesterolemia is often associated with obesity. It

appears that acupuncture can reduce hypercholesterolemia. Liu

at al found that the values of total cholesterol, triglyceride, LDL-

cholesterol, and VLDL-cholesterol were lower and the value of

HDL-cholesterol was higher in obese patients succesfully treated

with acupuncture. 24 insulin levels in these patients were also

higher than normal controls. It was observed by several

researches that there was pancreatic islet cell hypertrophy in

obesity suggesting the possibility of altered insulin metabolism.

Elevated fasting and postabsorptive insulin levels in non-diabetic

obese subjects have been found by a number of investigators.

High insulin level means increase glyconeogenesis and

lipogenesis which add more fat to the obese persons.

Hyperinsulinism is the condition where the body's insulin

levels are permanently high but there is resistency to the effects

of insulin. This condition promotes lipogenesis and with more

adiposity the insulin resistency increases. Hyperinsulinism also

provokes the liver to produce more LDL-cholesterol and

VLDL-cholesterol leading to hypercholesterolemia and

hypertriglyceridemia.

2,25

Acupuncture perhaps reduces

hypercholesterolemia by acting on hyperinsulinsm. In the above

study, insulin levels after acupuncture also decreased.

Acupuncture may affect the hyperinsulinsm through

alpha-adrenergic and beta-adrenergic receptors found in the beta

pancreatic cells.

The stimulation of the alpha-adrenergic

receptors by noradrenaf which is the neurOtransmitter in

sympathetic postganglionic synapses and also produced by the

adrenal medulla in small amount, inhibits the secretion of

insulin. Whereas the stimulation of beta-adrenergic receptors

by adrenalin which is produced by the adrenal medulla increases

insulin release.

14,27

There are also cholinergic receptors in the

Cermin Dunia Kedokteran No. 123, 1999 15

beta cells but vagal stimulation only increase insulin content in

the pancreatic venous effluent without any change in systemic

insulin level. It seems that beside the blood glucose level, the

factors that modulate the secretion of insulin both in basal

condition or in the course of response to various stimuli are the

balance between alpha-adrenergic and beta-adrenergic tonus.This

tonus is regulated by the autonomic nervous system through which

acupuncture can exerts its effects as has been described above.

Cermin Dunia Kedokteran No. 123, 1999

CONCLUSIONS

Body and auricular acupuncture can treat obesity. The

mechanisms are mainly through neurohumoral pathways. The

hypothalamus and the autonomic nervous system play major roles

in obesity and it is acting through these systems that acupuncture

exerts its effects on obese persons. The actions of acupuncture in

balancing disordered automatic tonus is typical of the traditional

concepts of acupuncture. The most important and elementary is

the Yin-Yang concept.

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Eat to live, but do not live to eat