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Method Article

Influence of Emotional Factors on the Efficacy of Acupuncture Treatment for Overweight Complicated with Hyperlipidemia: A Retrospective Cohort Study

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DOI:

10.3791/69257

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November 21st, 2025

 ,  ,  ,  ,  ,  ,  ,  , 
1Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, 2Key Laboratory of Acupuncture and Medicine Research of Ministry of Education, Nanjing University of Chinese Medicine

In This Article

Summary

This protocol details the acupuncture procedures for patients with overweight complicated by hyperlipidemia and certifies the influence of emotional factors on therapeutic efficacy based on metrics including BMI, cholesterol, and triglyceride levels.

Abstract

This retrospective study assessed the impact of emotional factors on acupuncture efficacy in patients with overweight and hyperlipidemia, to guide the development of a more comprehensive and personalized treatment protocol. Using standardized acupuncture procedures, we analyzed data from 1,128 patients, categorizing them into groups with or without emotional abnormalities based on Hamilton Anxiety Rating Scale (HAMA) scores (cutoff ≥14). After 1:1 propensity score matching, 436 patients were included, with comparable baseline characteristics (all P > 0.05). Both groups showed significant improvements in primary outcomes, including body weight, BMI, obesity degree, total cholesterol, triglycerides, HDL-C, and LDL-C after treatment (P < 0.05). However, the group with emotional abnormalities exhibited less pronounced improvements in body weight, BMI, obesity degree, total cholesterol, and triglycerides compared to the normal emotion group (P < 0.05). These findings indicate that while acupuncture significantly improves clinical outcomes in these patients, emotional abnormalities reduce its therapeutic efficacy. Future acupuncture protocols for the overweight should incorporate emotional factors to optimize treatment outcomes.

Introduction

Obesity is a complex, chronic metabolic disorder whose development and progression involve multiple factors. By 2021, 45.1% adults aged 25 years and older worldwide were affected by overweight and obesity. Concurrently, dyslipidemia has also shown a high global prevalence, with rates of 28.8% for hypertriglyceridemia, 24.1% for hypercholesterolemia, 38.4% for high-density lipoprotein cholesterol (HDL-C), and 18.93% for low-density lipoprotein cholesterol (LDL-C)1,2. In recent years, emotional disorders have received increasing attention in both the pathophysiological mechanisms and treatment processes of obesity. Clinical studies demonstrate a significant positive correlation between central obesity and its associated metabolic abnormalities and emotional disorders (such as anxiety and depression)3,4.Furthermore, mechanistic investigations have further revealed a positive feedback loop between obesity and emotional issues, indicating that anxiety and depressive moods can significantly influence metabolism-related hormone levels, including leptin, adiponectin, and insulin5,6.These hormones not only directly promote fat accumulation and metabolic disorders, leading to hypercholesterolemia and hypertriglyceridemia, but also exacerbate patients' emotional disorders by altering the feedback regulation mechanism of the hypothalamic-pituitary-adrenal (HPA) axis, the body's central stress response system7.

Acupuncture has been documented to effectively improve obesity8,9. However, in clinical practice, acupuncture protocols for obesity primarily focus on regulating gastrointestinal motility function, with insufficient attention given to emotional disorders such as anxiety and depression. Treatments predominantly select abdominal acupoints, including Zhongwan (CV12) and Tianshu (ST25), while seldom incorporating mood-regulating acupoints like Baihui (DU20) and Shenting (DU24)10,11.

After two decades of systematic research on acupuncture intervention for obesity conducted by our team, retrospective analysis of prior investigations reveals that across multiple treatment protocols for obesity disease, patients exhibiting emotional abnormalities as their predominant clinical presentation demonstrated significantly superior therapeutic outcomes from acupuncture12.This outcome may be closely associated with the inclusion of emotion-regulating needling techniques in such patients' acupuncture protocols. The incorporation of relevant acupoints potentially enhances therapeutic efficacy for obesity. Clinical observations indicate that other patients also manifest emotional abnormalities such as anxiety, though these present less prominently than other symptoms. Obesity and emotional disorders form a positive feedback loop through mechanisms, including leptin resistance and inflammatory factor cascade reactions13,14.

Building upon our team's prior research foundation, this study proposes the hypothesis that emotional abnormalities may function as an independent moderating variable mediating acupuncture's regulatory effects on lipid metabolism. To validate this hypothesis, we designed a retrospective research protocol targeting patients with overweight, aiming to determine whether significant differences exist in the influence of emotional factors on the therapeutic efficacy of acupuncture for overweight individuals complicated by hyperlipidemia. However, it should be noted that the retrospective design may limit the control over confounding variables, and the findings might be most applicable to patients with overweight complicated by hyperlipidemia. The findings will contribute to developing a more comprehensive acupuncture protocol for obesity.

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Protocol

This study received approval from the Ethics Committee of the Affiliated Hospital of Nanjing University of Chinese Medicine (Approval No DE2021-270-01). Designed as a retrospective cohort study, it enrolled patients with overweight (defined as BMI ≥24 kg/m2 according to Chinese guidelines) complicated by hyperlipidemia treated at the Department of Acupuncture and Rehabilitation of the Affiliated Hospital of Nanjing University of Chinese Medicine between June 2021 and August 202415. The cohort comprised 964 female and 164 male patients, aged 16 to 60 years. As a retrospective investigation, the sample size was determined by the actual number of patients with obtainable clinical data, without a priori sample size calculation.

1. Inclusion criteria

  1. Include patients with the following criteria:
    1. Patients with BMI ≥24 kg/m2
    2. Patients with total cholesterol (TC) ≥6.2 mmol/L or triglycerides (TG) ≥2.3 mmol/L or low-density lipoprotein cholesterol (LDL-C) ≥4.1 mmol/L16.
    3. Patients who agreed to undergo treatment with a signed informed consent form.

2. Exclusion criteria

  1. Exclude patients with the following criteria:
    1. Patients who have incomplete clinical data.
    2. Patients who fail to complete the Hamilton Anxiety Rating Scale (HAMA).

3. Grouping

  1. Classify patients using the Hamilton Anxiety Rating Scale (HAMA) as follows:
    1. Group A (Emotional Abnormality Group): Score ≥14 points.
    2. Group B (Emotional Normal Group): Score < 14 points.
  2. Administer the same acupuncture treatment to both groups.

4. Acupuncture Procedure

  1. Material Preparation: Prepare disposable sterile acupuncture needles (specification: 0.30 mm × 40 mm), medical sterile cotton swabs, and iodophor swabs (see Table of Materials).
  2. Position participants supine with knees extended, pelvis in neutral alignment, and acupoints appropriately exposed.
  3. Select acupoints according to WHO standards (Table 1). Bilateral Tianshu (ST25), Zusanli (ST36), Fenglong (ST40), Sanyinjiao (SP6), Quchi (LI11); Zhongwan (CV12), Guanyuan (CV4).
  4. Disinfect both the local skin at acupoints and the practitioner's fingers with iodophor swabs before needling.
  5. Hold the needle handle between the right thumb, index, and middle fingers. Insert needles perpendicularly (at a 90° angle) to a depth of 25 mm.
  6. Manipulate the needle with a reinforcing-reducing technique of 180° clockwise-counterclockwise rotation. Perform this manipulation at a frequency of approximately 60 times per min for 1 min, and repeat the manipulation every 10 min to elicit and sustain the characteristic Deqi sensation (sourness, numbness, distension, and heaviness)17,18,19.
  7. Maintain 30 min sessions every other day for 3 months. Ensure all interventions exclusively follow this standardized protocol during this period.

5. Definition of influencing factors

  1. Define smoking as either current or past tobacco use prior to the commencement of treatment. Classify alcohol consumption as any regular intake (≥ once per month) within the past 12 months.
  2. Define regular exercise as structured exercise (e.g., brisk walking, jogging, swimming) for ≥ 10 min/session, performed ≥ 3 times weekly, and dietary control as consistent adherence to a prescribed calorie-deficit diet throughout the clinical intervention.

6. Observation metrics

  1. Primary outcome measure: Change in BMI from baseline post-treatment: BMI (kg/m2) = Body Weight (kg) / Height2 (m2).
  2. Secondary outcome measures
    1. Measure body weight at baseline and post-treatment under fasting conditions in the morning using the same calibrated scale by a single investigator to ensure consistency and accurately assess changes in patient weight.
    2. Measure change in body weight and obesity degree from baseline post-treatment:
      1. Obesity degree = [(Actual Body Weight - Standard Body Weight) / Standard Body Weight] × 100%.
    3. Collect fasting venous blood samples at 8:00 AM, both pre- and post-treatment.
    4. Maintain samples at 14 °C immediately post-collection.
    5. Perform centrifugation of the samples at 2345 × g for 5 min using a centrifuge to isolate the serum fraction(see Table of Materials).
    6. Quantify serum levels of TC, TG, LDL-C, and HDL-C using enzymatic assays on an automated clinical chemistry analyzer(see Table of Materials).
      NOTE: Complete all analyses within 4 h of sample collection.

7. Statistical methods

  1. Analyze data using SPSS statistical software (see Table of Materials) and RStudio (see Table of Materials). Apply Propensity Score Matching (PSM) to ensure baseline group comparability. Set the random seed to 2000 for reproducibility. Perform propensity score matching using the MatchIt package in R. Apply a 1:1 nearest neighbor matching algorithm without replacement. Use a caliper width of 0.05 on the logit scale of the propensity score to prevent inadequate matches.
  2. Estimate propensity scores via a logistic regression model incorporating the following covariates: sex, age, course of disease, baseline body weight, baseline HAMA score, baseline BMI, drinking status, smoking status, exercise habits, dietary control, baseline TC, baseline TG, baseline LDL-C, and baseline HDL-C. Enforce exact matching on sex and age to ensure complete balance of these key demographic variables.
  3. Express categorical data as frequency (percentage) and compare using chi-square tests.
  4. Assess the normality of continuous variables using the Shapiro-Wilk test. Report normally distributed data as mean ± SD (x̄ ± s); use independent t-tests for between-group comparisons and paired t-tests for within-group comparisons.
  5. Report non-normally distributed data as median [P25, P75]; use the Mann-Whitney U test for between-group comparisons and the Wilcoxon signed-rank test for within-group comparisons.
  6. Define statistical significance at P < 0.05.

8. Safety assessment

  1. Record and manage adverse events, including infection, needling syncope, and hematoma occurring during the trial.

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Results

Both groups completed the 3-month treatment and follow-up. A total of 1,128 patients with overweight complicated by hyperlipidemia were initially enrolled, comprising 591 cases in Group A and 537 cases in Group B. Baseline characteristics between groups were imbalanced and lacked comparability (P < 0.05). Post-matching analysis included 218 cases in Group A and 218 cases in Group B (total n = 436). Baseline characteristics showed no statistically significant differences between matched...

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Discussion

This real-world retrospective cohort study ensured treatment consistency and standardization by implementing a uniform treatment protocol across all enrolled patients. Our team conducted rigorous reviews of each patient's treatment documentation to verify protocol compliance and performed comprehensive clinical follow-ups for all participants.

The most critical aspect of this protocol lies in the precise selection and localization of acupoints. All acupoints were identified and needled in ...

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Disclosures

The authors report no conflicts of interest.

Acknowledgements

We appreciate the financial support from the National Nature Science Foundation (81904290).

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Materials

List of materials used in this article
NameCompanyCatalog NumberComments
automated clinical chemistry analyzerBeckman CoulterAU5800
centrifugeBeckman CoulterAllegra X-15R
Disposable sterile acupuncture needlesSuzhou Medical Appliance Factory Ltd.20162200970For acupuncture
iodophor swabsTianjin Yuanhang Industry & Trade Development Co., Ltd.20202140083For sterilization
medical sterile cotton swabsXinxiang Huaxi Sanitary Materials Co., Ltd.20192140713For hemostasis
RstudioRstudio, PBChttps://rstudio.com/
SPSSInternational Business Machines CorporationVersion 27

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Acupuncture EfficacyOverweight PatientsHyperlipidemia TreatmentBody Mass IndexTriglyceride ReductionCholesterol LevelsDeqi SensationMood Regulation
Influence of Emotional Factors on the Efficacy of Acupuncture Treatment for Overweight Complicated with Hyperlipidemia: A Retrospective Cohort Study
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