BACKGROUND: Overweight and obesity have become global health concerns that contribute significantly to multiple life-threatening conditions. Moreover, excess body weight affects individuals’ physical and emotional health across all ages, genders and races/ethnicities. A variety of techniques have been employed to manage the effects of excess weight in order to reduce mortality and comorbidities, however there is still high prevalence of excess weight across the world.
PURPOSE: The purpose of this study was to investigate the efficacy of moxibustion therapy on weight loss, waist circumference and waist-to-hip ratio in young adult females.
METHODS: An explored study design was used. Fifty-one Asian females were enrolled. Inclusion criteria included age between 21-25 years old and waist circumference ≥ 80 cm while exclusion criteria included intolerance to moxibustion therapy and current illness. Two groups were formed and subjects in the experimental group received moxibustion sessions lasting 20 min and an educational video program for 30 min while participants in the control group received only the educational program every other week for 8 weeks. Dependent variable measurements (body weight, waist circumference and waist-to-hip ratio) were collected at baseline and follow-up for eight weeks.
RESULTS: Average body weight of the treatment group decreased significantly from 64.10 ± 2.99 kg to 62.79 ± 2.99 kg (p < 0.05) while average body weight in the control group did not decrease significantly (p = 0.058). Also, individuals in the moxibustion experimental group showed significant reductions (p < 0.05) in both waist circumference and waist-to-hip ratio.
CONCLUSION: Positive effects on anthropometry can be achieved by moxibustion intervention in conjunction with a weight loss education program. Future studies may focus on functional assessment of biomarkers associated with the immune system and relevant mechanisms of action.
Keywords: moxibustion therapy, weight reduction, waist circumference, waist-to-hip ratio
According to the World Health Organization (WHO, 2013) more than 1.4 billion adults 20 years of age and older were overweight in 2008 and over 200 million men and nearly 30 million women were obese. Sixty-five percent of the world’s population lives in countries where excess weight is a larger threat to health than underweight. Overweight refers to excessive body weight such that the body mass index (BMI; kg/m2) is > 25 while obesity refers to BMI > 30 [2, 22]. These standards for excess weight are commonly used in the US, Europe and Australia. The Centers for Disease Control and Prevention (CDC), the National Health and Nutrition Examination Survey (NHANES) and the National Health Interview Survey (NHIS) report that 6.3% of males and 8% of females 20 years of age and older have BMI values of 40 or higher and classify as extremely obese [3,4,5]. Such critical global health issues have raised the attention of healthcare providers and are also recognized to pose a potential harm to younger generations as well.
Excess weight can be assessed through other measures than BMI. Abdominal obesity, which is more common among men (who tend to have an android body fat distribution) than women (who tend to accumulate fat around the hips and thighs in a gynoid distribution), is another parameter that can be assessed to study overweight. The two most common ways to measure abdominal obesity are through waist circumference (WC) and comparing waist size to hip size (waist-to-hip ratio, WHR). WC is an anthropometric index commonly used as a proxy for abdominal fat mass [6, 24] which is calculated by placing a measuring tape around the abdomen at a horizontal level just above the hip bone. According to the classifications adopted by the American Heart Association and the National Heart, Lung, and Blood Institute of the US National Institutes of Health, elevated WC in males is defined as ≥ 102 cm and in females as ≥ 88 cm [9, 28]. Multiple prospective cohort research studies have shown that there is a relationship between abdominal obesity (assessed both by WC and WHR) and subclinical atherosclerotic vascular disease regardless of race, sex or age group . In particular, Lee and colleagues (2007) showed that WC and WHR predict coronary artery calcification (CAC) [25-27]. High WC values are also associated with other complications such as metabolic syndrome , which is a constellation of metabolic risk factors that negatively affect human health. The most common health consequences associated with excess weight include cardiovascular disease, diabetes, musculoskeletal disorders and some cancers .
The total annual cost related to the current prevalence of adolescent excess weight is estimated to be $254 billion in the US  and €59 billion from EU member states' pockets in direct health care costs . Certainly the ramifications of this global epidemic include limitations to the daily physical activities of excess weight individuals and also an increased economic burden . Given that childhood rates of excess weight continue to increase there is a need for effective interventions that can be employed as early as infancy to reverse the anticipated trends . Therefore, finding effective methods to treat excess weight in younger individuals is necessary.
Two popular alternative medicine treatments, acupuncture and moxibustion, arose from traditional Chinese medicine and share three similar principles: 1) the modification of central nervous system neurotransmitter levels through the repeated stimulation of acupoints; 2) enhancement of the body’s immune system; and 3) stimulation of the body through channel points [11-12, 30-33]. Moxibustion is unique from acupuncture in that it uses moxa to warm body regions and acupoints with the intention of stimulating circulation through the points and inducing a smoother flow of blood and qi [13, 30-33,43]. Moxibustion can be applied to patients directly (burn cones up to 1 cm in size are placed directly on the skin) or indirectly (a medium is placed in between the burning moxa and the skin). Moxibustion may be a good alternative for some patients who want to avoid penetration of the skin with needles during acupuncture. In total 361 channel points are acknowledged in Chinese medical books and they can be used to assess the pathological changes of the body to help diagnose disease and also as points for treatment [34-36].
Moxibustion interventions have been studied in both animal and human models. Several studies in animal models have demonstrated positive effects of moxibustion on females with excess body weight and endocrine issues. For example, Zhu and colleagues found preventive moxibustion had beneficial effects on fat accumulation, blood lipids, and estradiol (E2) levels in menopausal rats . Specifically they found that total plasma cholesterol decreased and the rate of body weight gain was slowed in the moxibustion treatment group compared with the control group in 14-month-old rats. These findings suggest moxibustion can have beneficial effects on both blood lipids and body weight management. Indices of spleen and thoracic gland function have also been measured as well as synoviocytes collected from knee joints. These results showed that overall moxibustion had a positive impact on pathological pathways of the immune system [38-39].
Other studies have shown that moxibustion can have beneficial effects on human health. For example a Chinese research study showed a strong link between polycystic ovary syndrome and obesity and insulin resistance in women. Women with these symptoms who were treated with moxibustion displayed increased expression of adiponectin, a protein associated with improved insulin sensitivity . Another relevant study looked at the effects of moxibustion treatment over three months in 150 Chinese women with climacteric syndrome. The points chosen for treatment were Quchi (LI 11), Zhongwan (CV 12), Tianshu (ST 25), Daheng (SP 15), Zusanli (ST 36), Shangjuxu (ST 37), Sanyinjiao (SP 6) and Neiting (ST 44). An intense moxibustion intervention was employed (subjects were treated every other day for three months). The outcome variables (including symptoms, physical signs, obesity index, Kupperman index, the vegetative equilibrium index (Value Y), estradiol (E2) and follicle stimulating hormone (FSH)) were observed before and after treatment. Significant reductions were seen after moxibustion treatment in the obesity index, Kupperman index, and FSH levels. The authors concluded that deficiencies in liver, spleen and kidney function may be associated with climacteric syndrome and should be closely monitored in obese individuals who are at risk for the syndrome . To date researchers have reported that moxibustion has worked on several populations, such as obese females with climacteric syndrome and polycystic ovary syndrome, gastric mucosal injury, weight gain/loss, short stature, kidney deficiency in children, and partial androgen deficiency in males [14-21].
A variety of treatments for excess weight exist, including changing lifestyle habits such as dietary and physical activity patterns and other behavioral changes and there are also weight-loss medicines and surgeries. There are also alternative medicine treatments for excess weight that are becoming increasingly popular. In the US, moxibustion/acupuncture, massage therapy, meditation, movement relaxation techniques, spinal manipulation, and Tai Chi were among the top ten most commonly used alternative medicine treatments in 2007 [13, 26, 41-42].
Demographics and study design
An explored study design was used to test the effects of indirect moxibustion on weight loss and abdominal obesity. Sixty participants were recruited from a private university in Taiwan in 2013 and were assigned to one of two groups (control or experimental) randomly by a computer-generated list, which was held confidential so no one except the principal investigator knew the treatment allocation of the patients. Inclusion criteria included: 1) age 21-25; 2) Asian female; and 3) WC ≥ 80 cm, which is deemed excessive for Asian females by the Bureau of Health Promotion, Department of Health, R.O.C. (Taiwan) . Exclusion criteria included: 1) medication allergies, 2) present illness (e.g. cold or flu), and 3) intolerance to moxibustion.
Demographic data were collected at the first visit. Institutional review board and ethical approval was obtained from the school (IRB NO.100-2867A3) and informed consent was obtained from each participant. All participants had the right to withdraw from the study at any time. No potential harm or risk from participating in the study was expected or reported. The potential benefits of participation in the study were weight loss, improved health and increased overall wellbeing.
The overall study design is depicted in Figure 1. A diet and daily activity education program was designed for each participant. Group A (the control group) was assigned to receive the education program and group B (the experimental group) received both the education program and moxibustion treatment. The programs were given at separate times in order to reduce bias. The program was a 30-minute educational video about healthy habits that focused on reduced-calorie diets and lifestyle modification techniques. After watching the educational video, all participants were allowed to ask questions regarding the video program and they were answered on the spot by a senior nurse who was familiar with the video. Body weight (BW), WC, and WHR were recorded for all participants every two weeks (four total times) throughout the study.
In the experimental group, each participant received 20 minutes of indirect moxibuston twice a week for a total of 8 weeks. The acupoints targeted for treating weight loss were the Guanyuan (RN4), Qihai (RN6), Shuifen (RN9), Xiawan (RN10) and Tianshu (ST25) points. A senior Chinese medical practitioner lit one end of a moxa stick (about 20 cm in length, roughly the shape and size of a cigar) and held it close to the area being treated for 20 minutes until the skin turned light pink and warm. After this desired effect was achieved, the moxa was extinguished. The practitioner made a brief pulse check after moxibuston.
During the 8 weeks of the study 9 participants withdrew for a variety of reasons and these 9 subjects are not included in the final analysis. The reasons given for withdrawing from the study included feeling uncomfortable with traditional Chinese medicine in general and in particular not liking the sensation of the burning moxibustion (experimental group, n=3), and not being able to keep up with the treatment schedule (control group, n=4; experimental group, n=2).
The data were analyzed using SPSS 19.0. Sample size power analysis was calculated following the statistical need (n=30 per group; power effect = 0.28) by using SPSS. The generalized estimating equations (GEE) were chosen for continuous outcomes. Data are expressed as means ± standard deviations unless otherwise noted.
Twenty-five (49%) subjects were in the moxibustion treatment group B and twenty six (51%) subjects were in the control group A. At baseline there were no significant differences (p > 0.01) between the two groups comparing BW (67.66 kg ± 2.78kg in group A vs. 64.10kg ± 2.99 kg in group B), WC (85.71 cm ± 2.08 cm in group A vs. 84.83 cm ± 3.27 cm in group B), or WHR; (0.8452 ± 0.107 in group A vs. 0.8250 + 0.1077 in group B). . The anthropometric characteristics of the participants at baseline are reported in Table 1.
During the eight weeks of treatment four major outcome variables (BW, BMI, WC, and WHR) were monitored in both groups. In the control group the females did not show a significant overall change in BW (67.80kg ± 2.77 kg at week one to 67.62 kg ± 2.71 kg at week eight); however, WC (86.07 cm ± 2.10 cm at week one to 86.44 cm ± 2.11 cm at week eight) and WHR (0.8459 ± 0.1033 at week one to 0.8488 ± 0.01093 at week eight) were elevated which indicated a trend of increasing size in those individuals. On the other hand, the participants who received moxibustion therapy were noted to have continual losses in BW (63.88 ± 2.96 kg at week one to 62.89 +± 2.98kg at week eight; p < 0.05), WC (84.36 cm +± 3.08 cm at week one to 81.73 cm ± 3.19 cm at week eight; p < 0.05) and WHR (0.8241 +± 0.00939 at week one to 0.8116 +± 0.01233 at week eight; p < 0.05). Thus, the moxibustion therapy in conjunction with the weight loss education program was able to decrease body weight in this study (Table 2).
Furthermore, we also administered a short questionnaire on the education program and moxibustion therapy to all participants. This questionnaire identified some potential intervention areas for our future research strategies. For instance, 13 responders recommended healthy, low-calorie recipes be provided in order to make it easier for them to adopt the lifestyle changes suggested in the program. Five responders suggested extending the follow-up moxibustion therapy out to six months. Their feedback and comments were based on their positive experiences with the moxibustion therapy over the two months of study. Four participants shared their experience that a meet-up support group could be an effective way to continually motivate people to prioritize their health and body image.
In the current study, 8 weeks of moxibustion therapy with a weight loss education program significantly decreased participants' BW, WC and WHR. The weight loss finding is supported by another study that assessed the efficacy of acupuncture treatment on weight over 3 months and showed significant weight loss (p < 0.05) in the treatment group . An additional study that treated 100 obese patients with acupuncture for 30 days also reported significant mean weight loss (p < 0.05) . Beyond weight loss effects, stimulation of acupuncture points has been shown to have additional benefits to anthropometry. A different study by our group  found that ear acupressure administered for 8 weeks decreased BW, WC and WHR. Similarly, Lien and colleagues  showed that auricular stimulation over 4 weeks decreased BW, WC and WHR.
There are several limitations to this study. The sample size was small and only included females. Additionally, we did not collect detailed demographic characteristics or perform clinical laboratory tests. In future studies we would seek to increase the sample size, include males, and investigate personal and family health histories (such as cardiovascular disease, kidney disease, diabetes, and some cancers associated with excess weight). We would also perform laboratory tests (such as cholesterol and low and high density lipoproteins) to better understand the physiological effects of moxibustion. Studies involving long-term treatment as well as follow-up after treatment would also be important considerations for future studies. Furthermore comparisons between moxibustion and acupuncture should be performed to assess their efficacy for treating body fat in specific regions such as the upper arms, abdomen, thighs and lower legs. Lastly, future studies should focus on elucidating the mechanisms by which moxibustion treatment affects body composition.
This study showed that moxibustion therapy given with a weight loss education program can decrease BW, WC and WHR in Asian females after eight weeks of treatment. These results suggest that moxibustion may offer an effective and economical treatment for excess weight that could be used in addition to more conventional treatments like exercise, diet control, medicine and surgery. However, there is no single cause for excess weight and thus there is no single approach that can help prevent or treat excess weight. Diet, exercise, and lifestyle choices are the cornerstone of weight management, but moxibustion may be an effective supplemental treatment when needed.
CONFLICT OF INTEREST
The authors received no financial support for this study and have no conflicts of interest to declare.
Total subjects (n=60)
(age = 21-25; gender = female; WC > 80 cm)
DV = BW, WC, and WHR
Computerized random grouping
Control Group (n=30)
Experiment Group (n=30)
Moxibustion treatment (20 min/twice/wk)
Education video (30 min/wk)
Education video (30 min/wk)
Outcome measurements: BW; WC; and WHR/2wk * 4 times (Total = 8 wks)
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