Stimulated by Li et al 2020, and Kim et al 2020.
I was looking around for a story, and I thought I ought to check through the Online First papers from Acupuncture in Medicine. I’m sure you frequently do the same. Another paper from Lisa’s team (see last week’s blog) caught my eye. She had mentioned it on Women’s Health Day, but there was a lot of other data too, so I am again a bit late to get to this one. It was published just over a month ago, so that is some improvement from last week.
I did see it when it came out, but it is an observational cohort study, and it didn’t tickle me intellectually until I saw this second, more recent paper with which to make a contrast.
They are both investigating the metabolic effects of acupuncture. One is a cohort of 80 women with polycystic ovarian syndrome and insulin resistance treated 3 times a week for 6 months, and the other is a sham controlled trial on 120 obese premenopausal women in whom metabolic parameters were measured before and after a 6-week course of biweekly acupuncture or sham.
I first became aware of the possibility of acupuncture having metabolic effects from Lisa’s research in women with PCOS. Initially this constituted improvements in hyperandrogenism,[3,4] and then the thing that surprised me the most was when effects on insulin resistance were demonstrated.[5–8] At this point it became clear to me that the metabolic influences required much more regular treatment than was practical in clinical practice, at least in the West.
This brings me back to the cohort who were treated 3 times per week for 6 months. Of course, this study was performed in China. I must have missed the protocol when it was published in 2015, and clearly also the pilot study published the following year.
In this cohort, after some 78 treatment sessions there was a highly significant drop in insulin resistance (as measured by HOMA-IR), which was maintained at 3 months follow-up. The HOMA-IR, which stands for Homeostatic Model Assessment of Insulin Resistance (insulin x glucose / 405) was still well into the abnormal range, which reflected a high fasting insulin in the presence of normal glucose.
Whilst checking for related papers, I stumbled across the next step. A protocol for an open-label comparison of acupuncture with metformin in obese women with PCOS.
So, what of the other paper I am highlighting from Acupuncture in Medicine?
This trial was based in Korea and randomised 120 obese premenopausal women to either 12 sessions of acupuncture or sham. The acupuncture treatment involved manual acupuncture to 2 points in each limb, and 2 midline points on the abdomen, and electroacupuncture (EA) to long needles inserted 50-80mm ‘horizontally’ at ST25 and ST28. From this I assume these needles were in the subcutaneous fat layer. The sham group received treatment with non-penetrating needles at all the same points apart from the long needles. These were inserted in the same way, but placed 2cm lateral to the ‘real’ points, and the EA was inactive.
By contrast, Lisa’s protocols involve low frequency EA applied to muscle in the abdominal wall and legs.
Weight, BMI and waist circumference diminished significantly in both groups with no difference between the groups. There were differences between the groups in L-carnitine and some short and intermediate acylcarnitines, but these differences are not easy to interpret. Carnitine is a quaternary ammonium compound that transports long-chain fatty acids into mitochondria to be oxidised (‘burnt’), so it is certainly relevant, and I guess that increased values might indicate greater activity in fat metabolism in general. If this is the case, it did not result in a difference in weight loss, but that may be a reflection of the rather short time course of this study.
What can I take away from this dip into the world of metabolic effects of acupuncture?
A lot of treatment is needed, EA should probably be applied to muscles rather than fat, and sham controls should be avoided. Oh and don’t get me started on missing the point in the control group!
1 Li J, Wu W, Stener-Victorin E, et al. A prospective pilot study of the effect of acupuncture on insulin sensitivity in women with polycystic ovary syndrome and insulin resistance. Acupunct Med Published Online First: 4 April 2020. doi:10.1177/0964528420902144
2 Kim K-W, Shin W-C, Choi MS, et al. Effects of acupuncture on anthropometric and serum metabolic parameters in premenopausal overweight and obese women: a randomized, patient- and assessor-blind, sham-controlled clinical trial. Acupunct Med Published Online First: 17 April 2020. doi:10.1177/0964528420912259
3 Stener-Victorin E, Waldenstrom U, Tagnfors U, et al. Effects of electro-acupuncture on anovulation in women with polycystic ovary syndrome. Acta Obstet Gynecol Scand 2000;79:180–8. doi:10.1034/j.1600-0412.2000.079003180.x
4 Jedel E, Labrie F, Odén A, et al. Impact of electro-acupuncture and physical exercise on hyperandrogenism and oligo/amenorrhea in women with polycystic ovary syndrome: a randomized controlled trial. Am J Physiol Metab 2011;300:E37–45. doi:10.1152/ajpendo.00495.2010
5 Stener-Victorin E, Baghaei F, Holm G, et al. Effects of acupuncture and exercise on insulin sensitivity, adipose tissue characteristics, and markers of coagulation and fibrinolysis in women with polycystic ovary syndrome: secondary analyses of a randomized controlled trial. Fertil Steril 2012;97:501–8. doi:10.1016/j.fertnstert.2011.11.010
6 Johansson J, Mannerås-Holm L, Shao R, et al. Electrical vs Manual Acupuncture Stimulation in a Rat Model of Polycystic Ovary Syndrome: Different Effects on Muscle and Fat Tissue Insulin Signaling. PLoS One 2013;8:e54357. doi:10.1371/journal.pone.0054357
7 Benrick A, Maliqueo M, Johansson J, et al. Enhanced insulin sensitivity and acute regulation of metabolic genes and signaling pathways after a single electrical or manual acupuncture session in female insulin-resistant rats. Acta Diabetol 2014;51:963–72. doi:10.1007/s00592-014-0645-4
8 Benrick A, Maliqueo M, Johansson J, et al. Erratum to: Enhanced insulin sensitivity and acute regulation of metabolic genes and signaling pathways after a single electrical or manual acupuncture session in female insulin-resistant rats [Acta Diabetologica, DOI 10.1007/s00592-014-0645-4]. Acta Diabetol 2015;52:219–20. doi:10.1007/s00592-014-0678-8
9 Zheng Y, Stener-Victorin E, Ng EHY, et al. How does acupuncture affect insulin sensitivity in women with polycystic ovary syndrome and insulin resistance? Study protocol of a prospective pilot study. BMJ Open 2015;5:e007757–e007757. doi:10.1136/bmjopen-2015-007757
10 Stener-Victorin E, Maliqueo M, Soligo M, et al. Changes in HbA 1c and circulating and adipose tissue androgen levels in overweight-obese women with polycystic ovary syndrome in response to electroacupuncture. Obes Sci Pract 2016;2:426–35. doi:10.1002/osp4.78
11 Stener-Victorin E, Zhang H, Li R, et al. Acupuncture or metformin to improve insulin resistance in women with polycystic ovary syndrome: Study protocol of a combined multinational cross sectional case-control study and a randomised controlled trial. BMJ Open 2019;9:1–10. doi:10.1136/bmjopen-2018-024733
12 Cummings M. Commentary: Controls for acupuncture – can we finally see the light? BMJ 2001;322:1578.