【作者】 张梅；

【导师】 张宏；

【作者基本信息】 广州中医药大学 ， 针灸推拿学， 2008， 博士

【摘要】 现代人由于生活方式的转变和生活水平的提高,成年人中有极大比例超重或肥胖,其中女性更多于男性。肥胖已成为21世纪全球健康问题,对肥胖问题的专门研究也成为医学界的热点之一。临床上要求减重的患者越来越多,更年期肥胖已成为临床的常见病及多发病,非常值得深入研究其病因、病机、理想而无副作用的治疗方法。穴位埋线疗法是在留针和埋针的基础上形成的,属于长效针疗法。近年用于治疗单纯性肥胖及女性更年期综合征取得良好疗效,并有治疗次数少、省时、经济、作用持久、疗效明显等优点。患者痛苦小,依从性好,值得进一步研究。女性更年期综合征与卵巢功能衰退有关,由于卵巢分泌雌激素和黄体素,功能减退后使正常的下丘脑—垂体—卵巢轴之间的平衡发生变化,回馈抑制作用减弱,于是产生下丘脑和垂体的功能亢进,表现为促性腺激素（FSH、LH）的分泌增加,因而影响自主神经中枢的调节作用。本研究的目的在以穴位埋线治疗女性更年期肥胖,并评估疗效;更年期妇女减重后,是否对其更年期综合征有所改善,是否对其生殖激素有调整作用。近年来,针灸疗法在治疗肥胖症及女性更年期综合征方面的研究报导很多,因施术简单、疗效确切、副作用少而受到医学界普遍关注。但是对更年期妇女肥胖问题的研究,不管在临床疗效或实验研究方面相对却很少,未来还有许多研究发展的空间。希望借着此课题,在前人的研究及经验累积上,进一步探讨治疗更年期肥胖有效、安全、可重复性的方法。第一部份:文献探讨肥胖是性激素失衡的一种状态。更年期妇女卵巢功能衰退,雌二醇E₂分泌迅速下降,FSH、LH上升,下丘脑—垂体—卵巢轴平衡失调,影响胰岛素、肾上腺皮质激素、生长激素等代谢异常,造成糖、脂肪代谢障碍,可能是更年期肥胖发病的重要环节。治疗更年期肥胖的方法主要有饮食控制、运动、药物。目前主要的药物有食欲抑制剂、消化抑制剂和性激素替代疗法。虽然可以达到减重的目的,但是也有一定的副作用。针灸具有简单、方便、操作容易的优势,自古以来在中医的治疗上占有极重要的地位。近年来针灸在治疗肥胖、代谢综合征、糖尿病、高脂血症、更年期综合征等疾病中显示出良好的效果。从现有的针灸动物实验和临床研究看来,针灸在治疗更年期肥胖有抑制食欲,调整性激素失衡,改善内分泌代谢异常的作用。尤其是女性生殖激素与更年期肥胖之间的关联,非常值得深入探讨,也有利于对更年期肥胖机理的整体把握。通过大量的文献研究,我们认为针灸治疗肥胖及更年期综合征有一定的科学基础及确切的临床疗效。以穴位埋线作为长效型的针刺治疗,不失为一种值得进一步深入研究探讨的治疗方法。本课题就是在上述基础上,观察穴位埋线治疗妇女更年期肥胖的临床效果,并进一步探讨,这种治疗方法对调整女性生殖激素E₂、FSH、LH的影响及其机理,以期能够对穴位埋线治疗更年期妇女肥胖提供理论依据和临床研究依据。第二部份:临床研究目的:本研究选用饮食控制+穴位埋线的疗法治疗更年期肥胖妇女,并与饮食控制组对照评估其临床疗效。方法:本研究设计是以1、饮食控制组收36位患者。2、饮食控制+穴位埋线组收36位患者。3、怕针或晕针患者优先编入饮食控制组计有10名患者。4、依患者志愿编入饮食控制组8名或饮食控制+穴位埋线组21名。5、其余患者依随机抽签方式编入饮食控制组18名或饮食控制+穴位埋线组15名。饮食控制组采用每人每日饮食热量摄取以1400kcal为参考标准,其中食物营养素成份:蛋白质约占15%、脂肪约占20%、糖类约占65%。本菜单仅提供患者每日餐饮的参考,但要求所有患者尽量避开高热量和油炸类食物的摄取。患者每日饮食由患者自行准备并记录于表格中,每2周交回医护人员检查,若有特殊异常的情况,请患者提出检讨。只要患者无暴饮暴食现象出现,大致维持平稳的饮食水平即可接受。穴位埋线组依据中医基本理论辨证论治分为五组治疗,每2周施治一次,三个月为一观察疗程。1、胃肠实热:治则清泄胃肠腑热。取穴内庭、足三里、中脘、上巨虚、天枢、三阴交等。2、肝郁气滞:治则舒肝理气、活血化瘀。取穴太冲、天枢、足三里、肝俞、期门、三阴交等。3、脾虚湿阻:治则健脾祛湿。取穴脾俞、上巨虚、天枢、足三里、三阴交、丰隆等。4、肾阴虚:治则滋养肝肾,育阴潜阳。取穴关元、肝俞、足三里、肾俞、三阴交、太冲等。5、肾阳虚:治则温肾扶阳。取穴关元、足三里、肾俞、脾俞、气海、三阴交等。结果:本课题以45-55岁的更年期肥胖妇女作为研究对象,通过查阅文献及临床研究,以饮食控制及穴位埋线治疗更年期肥胖的临床疗效分析,初步得出以下结论:1、针对肥胖症,饮食控制与穴位埋线都有显着疗效。以饮食控制作为有效治疗肥胖症的基础是得到印证。2、穴位埋线可以有效降低更年期肥胖妇女的体重、腰围及体重指数（BMI）较单纯用饮食控制来减重,效果更明显。3、针对更年期综合征kupperman指数（MI）,饮食控制与穴位埋线都有显着疗效,两者之间有显着差异。。4、穴位埋线的M工疗效总有效率与饮食控制比较有明显差异（p＜0.05）,提示穴位埋线在改善更年期综合征方面的疗效较好。5、饮食控制对肥胖妇女生殖激素（E₂、LH、FSH）的改变,没有影响。6、穴位埋线对肥胖妇女生殖激素（E₂、LH、FSH）的改变,达到显着差异饮食控制表现出有减重效果,但总有效率偏低,不影响生殖激素,且对更年期综合征症状改善帮助不大。穴位埋线不但有减重效果,同时能够调整失衡的生殖激素,进而改善更年期综合征。结论:穴位埋线能通过影响摄食,增加机体能量代谢,产生减肥效果。本研究结果显示,穴位埋线在治疗更年期妇女肥胖,取得良好减肥效果的同时,也同时改善更年期综合征。其作用机制可能是穴位埋线具有调整下丘脑—垂体—卵巢轴的作用,透过提升E₂含量,降低FSH、LH的含量,延缓下丘脑—垂体—卵巢轴系统功能的衰老,改善生殖激素失调所引发心血管系统、精神神经系统、代谢系统的功能紊乱。更多还原

【Abstract】 Due to modern lifestyle changes and improvement in living standards, a large proportion of adults are overweight or obese, more often women than men. Obesity has become a global health problem for the 21st century, and specialized research of obesity has become a hot spot in the medical world. Clinically there are more and more patients requesting help losing weight. Menopausal obesity has become a common, frequently seen clinical disease. It is extremely worthwhile to research its pathogenesis and etiology to find an ideal method of treatment without adverse side effects.Embedded needle acupoint therapy was formed on the basis of retaining and burying acupuncture needles, and thus is classified as a long-term effective treatment. In recent years its use in treating both simple obesity and female menopause syndrome has shown good results, additionally the treatments are few, time-saving, economical, have lasting effect, and show a clear effectiveness. As the treatment does not cause much pain and patients are compliant, it is worthwhile to continue further research.Female menopause and ovarian function recession are related. After ovarian secretions of estrogen and progesterone are reduced, a change in the normal balance of the hypothalamus, pituitary, and ovarian axis takes place. The negative feedback controls weaken, resulting in hyperactivity of the hypothalamus and pituitary, manifesting in an overproduction of gonadotropin （FSH, LH）, thus affecting the regulatory activity of the central nervous system. The purpose of this study is to treat female menopausal obesity using embedded needle acupoint therapy, and evaluate its efficacy; to see whether there is improvement in quality of life and adjustment in reproductive hormones after the menopausal women have lost weight.In recent years there have been many reports on the use of acupuncture in treating obesity and female menopause syndrome, because its applications are simple, effective, and with few side effects it has received widespread attention from the medical community. But research on the topic of female menopausal obesity, whether in the field of clinical efficacy or experimental research, is actually very rare, and leaves a lot of space for development of future research. Hopefully by addressing this issue, we can further investigate treatment of menopausal obesity by building on accumulated previous research and experience, to find a method of treatment that is safe, effective, and can be repeated.Part I: Literature ReviewObesity is one type of hormone imbalance condition. Menopausal women with receding ovarian function have rapidly declining secretion of estradiol （E₂）, an increase in FSH and LH, an imbalance of the hypothalamus-pituitary-ovarian axis, affecting insulin, adrenal cortex hormones, growth hormones and causing other metabolic disorders, resulting in dysfunction of sugar and fat metabolism, and showing an important probable link between the incidence of menopause and obesity.The main forms of treatment for menopausal obesity are a controlled diet, exercise, and medication. Currently the main forms of medication are appetite suppressants, digestion inhibitors, and hormone replacement therapy. Of course this can achieve the goal of losing weight, but there are certain side effects. Acupuncture is simple, convenient and easily administered. As a form of TCM treatment, from ancient times, acupuncture has always been held with great respect. In recent years the use of acupuncture to treat obesity, metabolic disorders, diabetes, hyperlipidemia, menopause syndrome, and other diseases has shown great results. Existing animal experiments and clinical research has shown that in treating menopausal obesity, acupuncture can suppress appetite, regulate hormone imbalances, and improve endocrine and metabolic abnormalities. The link between female reproductive hormones and menopausal obesity is especially worthwhile to investigate, and is also beneficial in obtaining an overall grasp of menopausal obesity mechanisms.After a lot of literary research, we feel that treatment of obesity and menopause syndrome using acupuncture has a definite scientific foundation and a precise clinical healing effect. Conducting a thorough research investigation of the use of embedded needle acupoint therapy as long term treatment method can still be considered very worthwhile. As based on the above mentioned foundation, a study of the efficacy of embedded needle therapy in treating female menopausal obesity, and a further investigation into this treatment methods affect on and mechanism of adjusting female reproductive hormones （E₂, FSH, LH） can improve the theoretical basis and establish a foundation for clinical research of the treatment of female menopausal obesity using embedded needle acupuncture.Part II: Clinical ResearchPurpose: This study will use both diet control and embedded needle therapy to treat female menopausal obesity, and will use the diet control group （control group） to evaluate clinical efficacy.Method: 1. 36 patients in the diet control group. 2. 36 patients in the diet control + embedded needle group. 3. 10 priority patients afraid of needles or with needle sickness were placed in the diet control group. 4. 8 patients were placed in the diet control group and 21 in the diet control + embedded needle group as based on their wishes. 5. Of the remaining patients 18 were placed in the diet control group and 15 in the diet control + embedded needle group as based on a random drawing.1400 kcal was set as the reference standard for daily caloric intake of patients in the diet control group, the nutritional breakdown of food was: 15% protein, 20% fats, and 65% carbohydrates. This menu merely provides a reference for patients to consult for daily meals, but all patients were requested to avoid intake of high-calorie and fried foods as much as possible. All daily meals were self prepared by the patients and recorded in a table, which was returned to medical personnel every two weeks for examination. If any unusual or abnormal situation occurred, the patient was asked to provide a self-review. As long as there was no appearance of patients engorging food, most were able to accept and maintain a steady level.The diet control + embedded needle group relied on TCM fundamental theory and pattern classification in splitting up 5 groups for treatment; reassessment was performed every two weeks, and 3 months was considered one observational treatment period.1. Stomach and intestine repletion heat: treatment based on clearing and draining heat from the stomach and intestine bowels. Acupoints: NeiTing, ZuSanLi, ZhongWan, ShangJuXu, TianShu, SanYinJiao, etc.2. Liver depression with qi stagnation: treatment based on comforting the liver and rectifying the qi, quickening the blood and transforming stasis. Acupoints: TaiChong, TianShu, ZuSanLi, GanShu, QiMen, SanYinJiao, etc.3. Spleen vacuity with damp obstruction: treatment based on fortifying the spleen and expelling dampness. Acupoints: PiShu, ShangJuXu, TianShu, ZuSanLi, SanYinJiao, FengLong, etc.4. Kidney Yin vacuity: treatment based on nourishing the kidney and liver, fostering yin and submerging yang. Acupoints: GuanYuan, GanShu, ZuSanLi, ShenShu, SanYinJiao, TaiChong, etc.5. Kidney Yang vacuity: treatment based on warming the kidney and aiding the yang. Acupoints: GuanYuan, ZuSanLi, ShenShu, PiShu, QiHai, SanYinJiao, etc.Results: A group of 45-55 year old women were used as research subjects for the study of female menopausal obesity. Through literature survey, clinical research, and analysis of clinical efficacy of diet control and embedded needle treatment of menopausal obesity, the following preliminary conclusions were made;1. Clear efficacy of diet control and embedded needle treatment of obesity.2. Diet control was regarded as the obtained basic validation for effective treatment of obesity.3. Diet control had little effect on changing reproductive hormones （E2, LH, FSH） of obese women.4. There was a clear difference in the achieved effect of embedded needle acupuncture in changing reproductive hormones （E2, LH, FSH） of obese women.5. For menopause syndrome the Blatt-Kupperman Menopausal Index （MI）, clear efficacy is seen of both diet control and embedded needle therapy, with no observed difference between the two groups. This result may be related to the mode of calculation, and thus a better measurement index must be considered.6. Only in the embedded needle acupuncture treatment of menopausal women did the MI efficacy achieve a notable difference （p<0.05）.Diet control showed results in weight loss, but the overall efficacy rate declined, with no effect on reproductive hormones, and not much help in improving symptoms of menopause syndrome. Embedded needle acupuncture not only showed results in weight loss, but at the same time was able to adjust imbalances in reproductive hormones, and thus improve menopause syndrome.Conclusion: Embedded needle acupuncture, by means of influencing food absorption and increasing the body’ s metabolic energy, can produce a slimming effect. Results of this study illustrate that treatment of female menopausal obesity using embedded needle acupuncture has good results in weight loss while also improving menopause syndrome. The active mechanism is possibly the adjusting effect of embedded needle acupuncture on the hypothalamus-pituitary-ovarian axis. By increasing levels of E₂ and decreasing FSH and LH levels, aging and loss of function of the hypothalamus-pituitary-ovarian axis system is delayed, improving disorders of the cardiovascular system, psychological and nervous system, and metabolic system triggered by imbalances in reproductive hormone levels.更多还原