Abstract
Background:
This study aimed to assess the comparative effectiveness of massage combined with lifestyle intervention and lifestyle intervention alone in patients with simple obesity.
Methods:
The PubMed, Embase, Cochrane Library, CNKI, VIP Database, and Wanfang Data were searched. Meta-analysis was conducted in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Primary outcomes were body weight (BW) and body mass index (BMI). Secondary outcomes were waist circumference (WC), hip circumference (HC), total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), fasting insulin (FINS), and homeostasis model assessment–insulin resistance (HOMA-IR) and adverse events.
Results:
Thirteen randomized controlled trials were included. The meta-analysis showed that massage combined with lifestyle intervention significantly decreased BW (mean difference [MD]: −4.85; 95% confidence interval [CI]: −8.25 to −1.46; P = .005), BMI (MD: −2.65; 95% CI: −4.05 to −1.24; P = .0002), WC (MD: −3.63; 95% CI: −6.28 to −0.98; P = .007), TC (MD: −0.52; 95% CI: −0.84 to −0.20; P = .001), TG (MD: −0.23; 95% CI: −0.45 to −0.02; P = .003), LDL-C (MD: −0.48; 95% CI: −0.54 to −0.42; P < .00001), HDL-C (MD: −0.11; 95% CI: −0.17 to −0.05; P = .0004), FINS (MD: −1.64; 95% CI: −3.16 to −0.12; P = .03), and HOMA-IR (MD: −0.42; 95% CI: −0.65 to −0.18; P = .0005) compared with lifestyle intervention alone. In subgroup analyses, more obvious reduction in BMI (P = .02, I2 = 80.3%) for the children and adolescents subgroup, more obvious reduction in HC (P = .04, I2 = 76.1%) for the adults subgroup, more significant reduction in TC (P < .00001, I2 = 98.3%), LDL-C (P < .00001, I2 = 95.6%), and HDL-C (P < .0001, I2 = 94.1%) for intermittent treatment subgroup and more significant reduction in TC (P < .00001, I2 = 95.9%) and HDL-C (P < .0001, I2 = 94.1%) for treatment times ≤30 subgroup were detected.
Conclusions:
Compared with lifestyle intervention alone, massage combined with lifestyle intervention significantly decreased BW, BMI, WC, TC, TG, LDL-C, FINS, and HOMA-IR, but produced less effect in increasing HDL-C. And different ages, treatment intervals, and treatment times can all affect treatment outcomes.
Keywords: lifestyle intervention, massage, meta-analysis, obesity
1. Introduction
Obesity refers to the state of excessive or abnormal body fat accumulation.[1] Simple obesity is the presence of obesity without other diseases, often caused by unhealthy lifestyles, including poor dietary habits and limited physical activity.[2] And, obesity has been regarded as 1 of the main risk factors for noncommunicable disorders, including cardiovascular diseases, diabetes, certain cancers, and disability.[3–5] The prevalence of obesity has steadily increased, making obesity a health concern worldwide.[6,7] According to the World Health Organization, in 2020, there were 1.9 billion overweight adults and 0.6 million obese adults.[8] Obesity has emerged as a leading health problem over the past century.[9]
The main treatment options with sufficient evidence-based support for obesity are lifestyle intervention, pharmacotherapy, and bariatric surgery.[9] Lifestyle interventions aimed at changing dietary behaviors and physical activity are usually the first choice for weight loss.[10,11] However, management of obesity through behavioral changes aiming at cutting down caloric intake and increasing physical activity is frequently unsuccessful,[12] making weight loss a goal that is very often difficult to achieve.[13,14] Thus, patients with obesity have begun seeking alternative forms of health care for weight loss.[15,16] Massage is such an appealing alternative to the increasingly obesity population.[15,17] And, massage has been widely used in the field of body contouring and weight loss in China, France, the United States, and many other nations.[18–20]
The effectiveness of massage on obesity is gradually being reported. Several early studies have shown improvements in body contour and skin texture after massage treatment.[18,19,21,22] Foster et al[23] have shown reductions in thigh and infraumbilical circumference following treatment with massage. A study conducted by Brightman et al[24] has demonstrated improvement in arm and postpartum abdominal and flank subcutaneous fat deposits and skin laxity after massage. Boey et al[25] have demonstrated that massage treatment can enhance the clinical outcome of cryolipolysis treatment. Lee et al[26] have shown a significant reduction in weight, waist circumference (WC), body mass index (BMI), and serum lipids level after massage treatment. Klaudia Antoniak et al[27] found that massage can make a favorable change in lipid profile in obese people. Nozomi Donoyama et al[28] observed that adiponectin levels in blood increased in mildly obese women after massage treatment. However, current evidence supporting massage for obesity is still largely limited. An early systematic review even advocated acupuncture/massage had no effect on body weight (BW).[29] Yet the review did not separate the effectiveness of massage on obesity from that of acupuncture and has not been generally accepted for not well-performed clinical trials.[29] Widespread use of massage for the treatment of obesity has been accompanied by a growing number of reports discussing the effects of massage on weight loss. It is important to objectively evaluate and analyze the efficacy of massage in obesity treatment. However, there are no systematic reviews and meta-analyses that focus on the treatment effectiveness of massage for patients with simple obesity. As an alternative method, massage therapy was usually conducted combined with lifestyle intervention for weight loss. Therefore, this systematic review and meta-analysis aimed to compare the clinical efficacy of massage combined with lifestyle intervention and lifestyle intervention alone for patients with obesity using randomized controlled trials (RCTs).
2. Materials and methods
2.1. Study registration
This systematic review and meta-analysis was registered in the International Prospective Register of Systematic Reviews database (CRD42022370830), and conducted in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement guidelines.[30]
2.2. Data sources
Three English-language databases (PubMed, Embase, and Cochrane Library) and 3 Chinese-language databases (China National Knowledge Infrastructure, VIP Database, and Wanfang Data) were systematically searched for eligible studies from inception to December 11, 2022. The publication language was restricted to Chinese and English. The search strategy consisted of the following 3 components: clinical condition (obesity, overweight), 1 intervention method (diet, meals, exercise, lifestyle, behavioral education), and another intervention method (massage, anmo, tuina, acupressure, manipulate*). The complete search strategy for PubMed is displayed in Table 1, and it was modified as necessary for other databases. In addition, the references of the published papers were also manually searched (in Chinese and English) to identify cited articles that had not been found in the electronic search.
Table 1.
Search strategy for the PubMed database.
Number | Search terms |
---|---|
#1 | Massage (MeSH) |
#2 | Anmo (MeSH) |
#3 | Tuina (MeSH) |
#4 | Acupressure (MeSH) |
#5 | Manipulate* (MeSH) |
#6 | Massage (ti, ab) |
#7 | Anmo (ti, ab) |
#8 | Tuina (ti, ab) |
#9 | Acupressure (ti, ab) |
#10 | Manipulate* (ti, ab) |
#11 | #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 |
#12 | Diet (MeSH) |
#13 | Meals (MeSH) |
#14 | Exercise (MeSH) |
#15 | Life style (MeSH) |
#16 | Behavioral education (MeSH) |
#17 | Diet (ti, ab) |
#18 | Meals (ti, ab) |
#19 | Exercise (ti, ab) |
#20 | Life style (ti, ab) |
#21 | Lifestyle (ti, ab) |
#22 | Behavioral education (ti, ab) |
#23 | #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19 or #20 or #21 or #22 |
#24 | Overweight (MeSH) |
#25 | Obesity (MeSH) |
#26 | Overweight (ti, ab) |
#27 | Obesity (ti, ab) |
#28 | #24 or #25 or #26 or #27 |
#29 | #11 and #23 and #28 |
ti, ab = title/abstract.
2.3. Eligibility criteria
RCTs that compared the effectiveness of massage combined with lifestyle intervention and lifestyle intervention alone for patients with simple obesity were considered eligible in our meta-analysis.
Studies were included if they met the following criteria. (1) The subjects were definitely classified as having simple obesity. (2) Eligible interventions were massage combined with lifestyle intervention, where lifestyle interventions involved diet, exercise, behavioral education, or a combination of these methods. The comparison group was lifestyle intervention without additional method. (3) Study design: RCT design. (4) Outcomes: BW, BMI, WC, hip circumference (HC), blood serum lipid level, blood glucose, insulin sensitivity, and adverse events.
The exclusion criteria were as follows: (1) studies with unclear diagnosis and treatment standards; (2) studies with subjects diagnosed as secondary obesity, such as drug-induced obesity, hypothalamic syndrome, pituitary adenoma, hypercortisolism, polycystic ovary syndrome, postpartum obesity; (3) studies with traditional Chinese medicine or western medicine as intervention means, and studies with nonmassage treatment as intervention means; (4) nonclinical research (animal experiment, meta-analysis, review, guideline, protocol, published abstracts, comments, or letters), personal experience, conference papers, and mechanism research studies with non-effect evaluation; and (5) studies that have been published twice or have similar research data.
2.4. Data extraction
Two reviewers (Lili Chen and Heli Niu) independently screened the studies using the software EndNote X9 and extracted the data of the included trials with a structured data extraction form by Microsoft Excel 2018 with the following information: first author’s name, publication year, country, language, sample size, mean age, male proportion, intervention and control, treatment duration, and reported outcomes. A third author (Huijuan Lou) verified these data.
2.5. Quality assessment
Two reviewers (Lili Zhang and Zepeng Zhang) independently assessed the quality of each trial according to the Cochrane Risk of Bias (RoB) 2.0 tool, which contained 7 domains: random sequence generation, allocation concealment, blinding of participants and investigators, the blindness of outcome assessments, incomplete outcome data, selective outcome reporting, and other biases.[31] Each domain was classified as “high,” “low,” or “unclear” risk of bias. Any disagreement was rechecked by a discussion with a third reviewer (Huijuan Lou). Another 2 investigators (Huijuan Lou and Lili Chen) independently assessed the overall evidence and certainty of evidence for each outcome with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, which divides evidence into very low, low, moderate, and high levels.[32] The discrepancies were resolved by a third reviewer (Gaofeng Wang).
2.6. Data synthesis
The meta-analysis was performed using RevMan 5.4 provided by the Cochrane Collaboration.[31] The mean difference (MD) with 95% confidence interval (CI) was calculated for each outcome before data pooling. Any heterogeneity among the included trials was evaluated by using I2 statistics. Specifically, 0 < I2 < 25% was defined as low heterogeneity, 25% < I2 < 50% as moderate heterogeneity, 50% < I2 < 75% as significant heterogeneity, and 75% < I2 < 100% as high heterogeneity.[33–35] The random-effects model was applied for synthesizing data because of the diversity of massage forms across the included studies.[36,37] The robustness of the pooled conclusion was assessed by using sensitivity analysis through the sequential exclusion of each trial. The P-value for the pooled conclusions was 2-sided, and the inspection level was 0.05. Potential publication bias was assessed by visualization of asymmetry in funnel plots (≥10 included studies).[38] Preplanned subgroup analyses of our estimates of treatment effect were conducted to explore the influence of different ages (children and adolescents [<18 years] or adults [≥18 years]), different treatment intervals (continuous treatment or intermittent treatment), and different treatment times (treatment times ≤30 or treatment times >30).
3. Results
3.1. Literature search
A total of 1324 articles were identified during the initial electronic search, and 978 articles were retained after removing 346 duplicate articles by EndNote X9. Then, 944 studies were excluded after reading the titles and abstracts, and the full-text versions of the remaining 34 articles were retrieved for further evaluation. A total of 21 studies were further excluded because of other interventions involved,[39–41] lack of appropriate control,[42–52] incomplete or unqualified data,[53–55], and secondary obesity.[56–60] One new eligible study[61] was obtained by reviewing the reference lists of the included studies. Finally, a total of 13 studies were selected for the meta-analysis (Fig. 1).
Figure 1.
PRISMA flow chart for literature search and study selection. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analysis.
3.2. Study characteristics and quality assessment
The baseline characteristics of the included studies are summarized in Table 2. All of the trials were carried out in China, and a total of 848 subjects with obesity were enrolled. The treatment duration ranged from 14 days to 5 months, and 18 to 116 individuals were included in each trial. The Cochrane RoB 2.0 tool was used to evaluate the methodological quality of each of the included RCTs (Fig. 2). There were some concerns related to bias associated with different reasons. Nine trials[61–63,65,67–71] used a completely random design, with only 4 trials[62,63,67,69] definitely describing computer-generated randomization. One trial[66] grouped the participants based on their wishes. Three of the included studies[64,72,73] failed to clearly describe random sequence generation. All the included trials were considered to have an unclear risk of bias for reporting no information about allocation concealment. Owing to the characteristics of massage, it is difficult to conduct blinding for participants and personnel; hence, all of the included studies[61–73] were assessed as having a high risk of bias in the performance bias. None of the included studies[61–73] reported their outcome-assessment methods. We judged all 13 trials[61–73] as having a low risk of reporting bias given that the reported outcome measures were in accordance with those listed in the methods section. We did not identify any other potential sources of bias. In all, the overall bias of the 13 studies was mainly related to the allocation concealment, blinding of participants and investigators, and the blindness of outcome assessments.
Table 2.
Characteristics of the included studies and patients.
Author (yr) | Location/language | Sample size (In: Co) | Age (yr) | Male (%) | Intervention | Control | Treatment duration | Inclusion criteria | Adverse events | Course of disease (yr) | Outcomes |
---|---|---|---|---|---|---|---|---|---|---|---|
Benling Wang (2010)[59] | Jinan, China/Chinese | 60 (30/30) | 18–65 yr | NA | D + E + M | D + E | 8 wks | BMI ≥ 28.0 kg/m2 | NA | NA | TC, TG, HDL-C, LDL-C |
Bohua Yan (2014)[61] | Chengdu, China/English | 60 (30/30) | 30–55 yr/25–53 yr | 10% | D + E + M | D + E | 8 wks | BMI ≥ 25.0 kg/m2 | NA | 2.4–5.0 yr/2.0–7.0 yr | BW, BMI, WC, HC |
Fengyan Long (2019)[62] | Fangchenggang, China/Chinese | 95 (47/48) | 10.03 ± 2.15 yr/9.82 ± 2.30 yr | 57.90% | D + E + P + M | D + E + P | 12 wks (84 d) | BMI > 26 kg/m2 | None | 2.73 ± 0.77 yr/2.75 ± 0.93 yr | BW, WC, BMI, TC, TG, HDL-C, LDL-C |
Hongling Li (2003)[63] | Zhengzhou, China/Chinese | 60 (30/30) | 6–15 yr | 80% | D + E + P + M | D + E + P | 30 d | BMI > 30 kg/m2 | NA | NA | BW, BMI |
Hongyan Liu (2022)[64] | Beijing, China/Chinese | 116 (58/58) | 15.20 ± 2.15 yr/16.31 ± 2.09 yr | 56.9% | E + M | E | 4 wks (14 d) | BMI > 30 kg/m2 | NA | NA | BW, BMI, TG, HDL-C, LDL-C, TC, 2hFPG. |
Huimei Li (2010)[65] | Jinan, China/Chinese | 67 (33/34) | 19–64 yr/19–62 yr | 29.90% | D + E + M | D + E | 8 wks | BMI ≥ 28.0 kg/m2 | NA | 1–28 yr | BW, WC, HC, BMI |
Shengce Jiang (2014)[60] | Duyun, China/Chinese | 20 (10/10) | 28.4 ± 3.9 yr/29.5 ± 5.4 yr | 0% | D + E + P + M | D + E + P | 12 wks (84 d) | BMI > 30 kg/m2 | NA | NA | BW, BMI, TG, TC, LDL-C, HDL-C |
Wei Ju (2015)[66] | Zhengzhou, China/Chinese | 60 (30/30) | 9–15 yr | NA | D + E + P + M | D + E + P | 2 mo (60 d) | BMI > 30 kg/m2 | NA | NA | BMI, TC, TG, LDL-C, HDL-C |
Xiantao Tai (2006)[67] | Kunming, China/Chinese | 38 (18/20) | 6–14 yr | 52.63% | D + E + P + M | D + E + P | 15 wks (45 d) | BW > y × 2 + 8 | Transient increased appetite | NA | BW, BMI; HC, WC, WHR |
Yanpeng Ni (2017)[68] | Luoyang, China/Chinese | 90 (45/45) | 41.4 ± 7.5 yr/40.3 ± 6.7 yr | 65.56% | D + E + M | D + E | 5 mo | BMI > 24 | NA | NA | BMI |
Yin Guo (2011)[69] | Shanghai, China/Chinese | 42 (24/18) | 17.3 ± 3.6 yr/16.3 ± 2.8 yr | 47.60% | D + E + P + M | D + E + P | 4 wks (28 d) | BFI > 40% | NA | NA | BW, WC, HC, BMI |
Yuan Wang (2021)[70] | Yaan, China/Chinese | 80 (40/40) | 6.34 ± 3.67 yr/6.88 ± 3.56 yr | 52.50% | D + E + M | D + E | NA | BMI > 30 kg/m2 | NA | NA | BW, BMI, WC, HC, FPG,2hPG, FINS, IAI, HOMA-IR |
Yuehong Zhang (2015)[71] | Zhengzhou, China/Chinese | 60 (30/30) | 5–12 yr | 65% | D + E + M | D + E | 2 mo (60 d) | BMI > 30 kg/m2 | NA | NA | BW, BMI, WC, HC, FPG, 2hPG, FINS, IAI, HOMA-IR |
2hPG = 2-hour postprandial blood glucose, BMI = body mass index: body weight, Co = control, D = diet, E = exercise, FINS = fasting insulin, FPG = fasting plasma glucose, HC = hip circumference, HDL-C = high-density lipoprotein cholesterol, HOMA-IR = homeostasis model assessment–insulin resistance, IAI = insulin action index, In = intervention, LDL-C = low-density lipoprotein cholesterol, M = massage, P = psychology, TC = total cholesterol, TG = triglyceride, WC = waist circumference.
Figure 2.
Risk of bias.
3.3. Primary outcomes
3.3.1. Body weight
Eight trials[62–65,68,69,71,73] reported the effect of massage combined with lifestyle intervention compared with lifestyle intervention alone on BW. There was a total of 492 subjects included, with 248 subjects in the experimental groups and 244 subjects in the control groups. There was significant heterogeneity across the included trials (I2 = 83%; P < .00001). Hence, the sources of heterogeneity were evaluated through sensitivity analysis. After deleting each single study one by one, there was no distinct change in the MD and 95% CI of the appraisal of BW, suggesting stable outcomes (Table S1, Supplemental Digital Content, http://links.lww.com/MD/O236). The outcomes showed that the use of massage combined with lifestyle intervention was associated with a decrease in BW compared with lifestyle intervention alone (MD: −4.85; 95% CI: −8.25 to −1.46; P = .005; Fig. 3). Based on the GRADE framework, the outcomes of massage combined with lifestyle intervention on BW compared with lifestyle intervention alone were considered as moderate-quality evidence (Table 3).
Figure 3.
Effect of massage combined with lifestyle intervention compared with lifestyle intervention alone on body weight. CI= confidence interval, SD = standard deviation.
Table 3.
GRADE evaluation and recommendations strength.
Outcomes | Relative effect (95% CI) | Importance | No. of participants (studies) | Quality of the evidence (GRADE) | Comments |
---|---|---|---|---|---|
BW | MD: −4.85 (−8.25 to −1.46) | Critical | 492 (8 studies) | ⊕⊕⊕⊝ Moderatea |
May decrease the BW |
BMI | MD: −2.65 (−4.05 to −1.24) | Critical | 782 (12 studies) | ⊕⊕⊝⊝ Lowa,b |
May decrease the BMI |
WC | MD: −3.63 (−6.28 to −0.98) | Important | 296 (5 studies) | ⊕⊕⊝⊝ Lowa,c |
May lower the WC |
HC | MD: −0.98 (−2.26 to 0.30) | Important | 201 (4 studies) | ⊕⊕⊝⊝ Lowa,c |
May lower the HC |
TC | MD: −0.33 (−0.84 to 0.18) | Not important | 351 (5 studies) | ⊕⊝⊝⊝ Very lowa,b,c |
May lower the level of TC |
TG | MD: −0.37 (−0.60 to −0.13) | Not important | 351 (5 studies) | ⊕⊕⊝⊝ Lowa,c |
May lower the level of TG |
HDL-C | MD: −0.02 (−0.15 to 0.11) | Not important | 351 (5 studies) | ⊕⊕⊝⊝ Lowa,c |
No definite conclusion can be drawn |
LDL-C | MD: −0.23 (−0.45 to −0.02) | Not important | 351 (5 studies) | ⊕⊕⊝⊝ Lowa,c |
May lower the level of HDL-C |
FPG | MD: −0.10 (−0.22 to 0.02) | Not important | 140 (2 studies) | ⊕⊕⊝⊝ Lowa,c |
No definite conclusion can be drawn |
2hPG | MD: 0.08 (−0.57 to 0.74) | Not important | 140 (2 studies) | ⊕⊕⊝⊝ Lowa,c |
No definite conclusion can be drawn |
FINS | MD: −1.64 (−3.16 to −0.12) | Not important | 140 (2 studies) | ⊕⊕⊝⊝ Lowa,c |
May lower the level of FINS |
HOMA-IR | MD: −0.42 (−0.65 to −0.18) | Not important | 140 (2 studies) | ⊕⊕⊝⊝ Lowa,c |
May lower the level of HOMA-IR |
IAI | MD: −0.02 (−1.03 to 0.99) | Not important | 140 (2 studies) | ⊕⊝⊝⊝ Very lowa,b,c |
No definite conclusion can be drawn |
2hPC = 2-hour postprandial blood glucose, BMI = body mass index, BW = body weight, CI = confidence interval, FINS = fasting insulin, FPG = fasting plasma glucose, HC = hip circumference, HDL-C = high-density lipoprotein cholesterol, HOMA-IR = homeostasis model assessment–insulin resistance, IAI = insulin action index, LDL-C = low-density lipoprotein cholesterol, MD = mean difference, TC = total cholesterol, TG = triglyceride, WC = waist circumference.
aDowngraded because of serious risk of bias (no blinding).
bDowngraded because of serious inconsistency (I2 = 90%, point estimates and CI vary considerably).
cDowngraded because of serious imprecision (small sample size).
Downgraded because of serious inconsistency (I2 = 98%, point estimates and CI vary considerably).
3.3.2. Body mass index
Data on the effect of massage combined with lifestyle intervention compared with lifestyle intervention alone on BMI were reported in 12 trials.[61–66,68–73] There was a total of 782 subjects included, with 393 subjects in the experimental groups and 389 subjects in the control groups. The results showed that there was a high heterogeneity between trials (P < .00001, I2 = 97%). As a result, the sources of heterogeneity were evaluated through sensitivity analysis. After excluding any single study one by one, no remarkable change in the MD and 95% CI of the evaluation of BMI was found, pointing out stable results (Table S2, Supplemental Digital Content, http://links.lww.com/MD/O236). In accordance with the results of the meta-analysis, massage combined with lifestyle intervention could decrease BMI (MD: −2.65; 95% CI: −4.05 to −1.24; P = .0002; Fig. 4) compared with lifestyle intervention alone. Based on the GRADE framework, the outcomes of BMI were classified as low-quality evidence (Table 3).
Figure 4.
Effect of massage combined with lifestyle intervention compared with lifestyle intervention alone on body mass index. CI= confidence interval, SD = standard deviation.
The number of included studies was >10, so the publication bias was examined. For all of the included studies involving BMI, the funnel plots showed no remarkable asymmetry, implying no obvious publication bias existed (Fig. 5).
Figure 5.
Funnel plot of the effect of massage combined with lifestyle intervention compared with lifestyle intervention alone on body mass index. MD = mean difference.
3.4. The secondary outcomes
3.4.1. Waist circumference and hip circumference
Five trials reported the effect of massage combined with lifestyle intervention compared with lifestyle intervention alone on WC.[62–65,68] There was a total of 296 subjects included, with 150 subjects in the experimental groups and 146 subjects in the control groups. There was a high heterogeneity across the included trials (I2 = 84%; P < .0001). Thus, the sources of heterogeneity were detected through sensitivity analysis. After taking away the included trials one by one, there were no obvious changes in the MD and 95% CI of the assessment of WC (Table S3, Supplemental Digital Content, http://links.lww.com/MD/O236). The overall outcomes showed that the use of massage combined with lifestyle intervention was associated with a decrease in WC compared with lifestyle intervention alone (MD: −3.63; 95% CI: −6.28 to −0.98; P = .007; Fig. 6A).
Figure 6.
Effect of massage combined with lifestyle intervention compared with lifestyle intervention alone on waist circumference (A) and hip circumference (B). CI= confidence interval, SD = standard deviation.
Four trials[62,64,65,68] reported the effect of massage combined with lifestyle intervention compared with lifestyle intervention alone on HC. There was a total of 201 subjects included, with 103 subjects in the experimental groups and 98 subjects in the control groups. There was moderate heterogeneity across the included trials (I2 = 38%; P = .18). The overall results showed that patients treated with massage combined with lifestyle intervention had no obvious reduction in HC (MD: −0.98; 95% CI: −2.26 to 0.30; P = .13; Fig. 6B) compared with lifestyle intervention alone.
In accordance with the GRADE framework, both the quality of WC and that of HC were classified as low-quality evidence (Table 3).
3.4.2. Serum lipids
Data on the effect of massage combined with lifestyle intervention compared with lifestyle intervention alone on 4 different blood serum lipid components (total cholesterol [TC], triglyceride [TG], low-density lipoprotein cholesterol [LDL-C], and high-density lipoprotein cholesterol [HDL-C]) were all reported in the same 5 trials.[61,63,71–73] There was a total of 351 participants included, with 175 participants in the experimental groups and 176 participants in the control groups.
For TC, a significant heterogeneity was observed among the included trials (I2 = 93%; P < .00001). To assess the sources of heterogeneity, the sensitivity analysis was conducted by removing the included studies one by one. After taking away the most heterogeneous study[72] (Table S4, Supplemental Digital Content, http://links.lww.com/MD/O236), the overall results showed that the use of massage combined with lifestyle intervention was associated with an evident decrease in TC compared with lifestyle intervention alone (P = .08, I2 = 56%; MD: −0.52; 95% CI: −0.84 to −0.20; P = .001; Fig. 7A).
Figure 7.
Effect of on massage combined with lifestyle intervention compared with lifestyle intervention on different blood serum lipid components: (A) TC, (B) TG, (C) LDL-C, and (D) HDL-C. CI = confidence interval, HDL-C = high-density lipoprotein cholesterol, LDL-C = low-density lipoprotein cholesterol, SD = standard deviation, TC = total cholesterol, TG = triglyceride.
For TG, apparent heterogeneity was detected among the included studies (I2 = 88%; P < .00001). This result was not clearly altered after cutting out the individual trials one by one (Table S5, Supplemental Digital Content, http://links.lww.com/MD/O236). The ultimate outcomes showed that the application of massage combined with lifestyle intervention could reduce the level of TG compared with lifestyle intervention alone (MD: −0.23; 95% CI: −0.45 to −0.02; P = .003; Fig. 7B).
For LDL-C, distinct heterogeneity was detected among the included trials (I2 = 88%; P < .00001). The sources of heterogeneity were thereby appraised by sensitivity analysis. After removing the most heterogeneous study[63] (Table S6, Supplemental Digital Content, http://links.lww.com/MD/O236), the results showed that the application of massage combined with lifestyle intervention was related to a decrease in LDL-C compared with lifestyle intervention alone (P = 1.00, I2 = 0%; MD: −0.48; 95% CI: −0.54 to −0.42; P < .00001; Fig. 7C).
In HDL-C level, heterogeneity was found among the included trials (I2 = 77%; P = .002). By removing the most heterogeneous study[63] (Table S7, Supplemental Digital Content, http://links.lww.com/MD/O236), the overall results showed that the application of massage combined with lifestyle intervention was related to a decrease in the level of HDL-C compared with lifestyle intervention alone (P = .45, I2 = 0%; MD: −0.11; 95% CI: −0.17 to −0.05; P = .0004; Fig. 7D).
In accordance with the GRADE framework, the quality of evidence of TC, TG, LDL-C, and HDL-C outcomes was classified as very low, low, low, and low, respectively (Table 3).
3.4.3. Blood glucose and insulin sensitivity
Data on the effect of massage combined with lifestyle intervention compared with lifestyle intervention alone on blood glucose and insulin sensitivity (fasting plasma glucose [FPG], 2-hour postprandial blood glucose, fasting insulin [FINS], homeostasis model assessment–insulin resistance [HOMA-IR], and insulin action index [IAI]) were reported in the same 2 trials.[67,70] There was a total of 140 subjects included, with 70 subjects in the experimental groups and 70 subjects in the control groups. As shown in Figure 8, there was no significant change of FPG (P = .87, I2 = 0%; MD: −0.10; 95% CI: −0.22 to 0.02; P = .11; Fig. 8A), 2hPG (P = .98, I2 = 0%; MD: 0.08; 95% CI: −0.57 to 0.74; P = .81; Fig. 8B) and IAI (P < .00001, I2 = 97%; MD: −0.02; 95% CI: −1.03 to 0.99; P = .97; Fig. 8E) after massage combined with lifestyle intervention compared with lifestyle intervention alone. However, the results illustrated that the use of massage combined with lifestyle intervention was related to a decrease in FINS (P = .59, I2 = 0%; MD: −1.64; 95% CI: −3.16 to −0.12; P = .03; Fig. 8C) and HOMA-IR (P = .18, I2 = 45%, MD: −0.42; 95% CI: −0.65 to−0.18; P = .0005; Fig. 8D) compared with lifestyle intervention alone.
Figure 8.
Effect of massage combined with lifestyle intervention compared with lifestyle intervention on blood glucose and insulin sensitivity: (A) FPG, (B) 2hPC, (C) FINS, (D) HOMA-IR, and (E) IAI. 2hPC, 2-hour postprandial blood glucose, CI= confidence interval, FINS = fasting insulin, FPG = fasting plasma glucose, HOMA-IR = homeostasis model assessment–insulin resistance, IAI = insulin action index, SD = standard deviation.
The quality of evidence for FPG, 2-hour postprandial blood glucose, FINS, and HOMA-IR was low, and that for IAI was very low in accordance with the GRADE framework (Table 3).
3.4.4. Adverse events
Adverse events were reported in only 2 trials. One study reported no adverse events,[63] and the other reported transiently increased appetite.[68]
3.5. Subgroup analyses
3.5.1. Subgroup analyses by different ages
Since some of the included studies focused on children and adolescents (<18 years), while others focused on adult or elderly subjects (≥18 years), the effects may vary among different age groups. So, we carried out subgroup analyses after stratifying for the age of the subjects. The results revealed that no significant differences between subgroups were detected in BW (P = .97, I2 = 0%), WC (P = .27, I2 = 16.4%), TC (P = .26, I2 = 20.8%), TG (P = .62, I2 = 0%), LDL-C (P = .08, I2 = 67.9%), and HDL-C (P = .36, I2 = 0%), but more obvious reduction in BMI (P = .02, I2 = 80.3%) for the children and adolescents (<18 years) subgroup and more obvious reduction in HC (P = .04, I2 = 76.1%) for the adults (≥18 years) subgroup (Table 4).
Table 4.
Subgroup analyses by different ages.
Outcomes | Children and adolescents subgroup | Adults subgroup | Subgroup differences | ||
---|---|---|---|---|---|
MD (95% CI) | Heterogeneity | MD (95% CI) | Heterogeneity | ||
BW | −4.65 (−10.88, 1.58) | P = .0004, I2 = 80% | −4.50 (−7.89, −1.11) | P = .05, I2 = 66% | P = .97, I2 = 0% |
BMI | −3.79 (−5.00, −2.58) | P = .0004, I2 = 76% | −1.49 (−3.08, 0.10) | P < .00001, I2 = 96% | P = .02, I2 = 80.3% |
WC | −1.93 (−6.68, .81) | P = .03, I2 = 72% | −5.22 (−8.69, −1.74) | P = .04, I2 = 75% | P = .27, I2 = 16.4% |
HC | 0.00 (−1.51, 1.51) | P = .52, I2 = 0% | −1.84 (−2.76, −0.92) | P = .62, I2 = 0% | P = .04, I2 = 76.1% |
TC | −0.19 (−0.87, 0.50) | P < .00001, I2 = 97% | −0.65 (−1.08, −0.22) | P = .62, I2 = 0% | P = .26, I2 = 20.8% |
TG | −0.12 (−0.35, 0.10) | P < .00001, I2 = 93% | −0.75 (−1.40, −0.09) | P = .13, I2 = 57% | P = .08, I2 = 67.9% |
LDL-C | −0.35 (−0.63, −0.06) | P < .00001, I2 = 94% | −0.46 (−0.83, −0.10) | P = .91, I2 = 0% | P = .62, I2 = 0% |
HDL-C | 0.00 (−0.17, 0.18) | P = .0004, I2 = 87% | −0.10 (−0.25, 0.05) | P = .31, I2 = 1% | P = .36, I2 = 0% |
BMI = body mass index, BW = body weight, HC = hip circumference, HDL-C = high-density lipoprotein cholesterol, LDL-C = low-density lipoprotein cholesterol, TC = total cholesterol, TG = triglyceride, WC = waist circumference.
3.5.2. Subgroup analyses by different treatment intervals
Given that the massage treatment interval varied among the included studies, including once a day, once every other day, or 2 to 3 times a week with a rest at the weekend, subgroup analyses were conducted according to different treatment intervals. We define daily massage as continuous treatment, while treatment once every other day or 2 to 3 times a week with weekend rest as intermittent treatment. The results revealed that no obvious differences between subgroups were presented in BW (P = .20, I2 = 39.2%), BMI (P = .45, I2 = 0%), WC (P = .16, I2 = 48.6%), HC (P = .25, I2 = 23.5%), and TG (P = .16, I2 = 49.5%), but more significant reduction in TC (P < .00001, I2 = 98.3%), LDL-C (P < .00001, I2 = 95.6%), and HDL-C (P < .0001, I2 = 94.1%) for intermittent treatment subgroup (Table 5).
Table 5.
Subgroup analyses by different ages.
Outcomes | Continuous treatment | Intermittent treatment | Subgroup differences | ||
---|---|---|---|---|---|
MD (95% CI) | Heterogeneity | MD (95% CI) | Heterogeneity | ||
BW | −2.63 (−8.23, 2.98) | P = .03, I2 = 66% | −6.95 (−10.43, −3.46) | P = .002, I2 = 80% | P = .20, I2 = 39.2% |
BMI | −2.08 (−3.53, −0.64) | P = .002, I2 = 73% | −3.11 (−5.35, −0.87) | P < .00001, I2 = 99% | P = .45, I2 = 0% |
WC | −1.47 (−5.65, 2.71) | P = .01, I2 = 85% | −4.50 (−5.30, −3.69) | P = .0002, I2 = 88% | P = .16, I2 = 48.6% |
HC | 1.20 (−2.77, 5.17) | Not applicable | −1.22 (−2.46, 0.01) | P = .20, I2 = 38% | P = .25, I2 = 23.5% |
TC | 0.14 (−0.04, 0.32) | P = .25, I2 = 29% | −0.69 (−0.82, −0.57) | P = .94, I2 = 0% | P < .00001, I2 = 98.3% |
TG | −0.06 (−0.20, 0.09) | P = .18, I2 = 41% | −0.65 (−1.45, 0.16) | P = .03, I2 = 80% | P = .16, I2 = 49.5% |
LDL-C | −0.18 (−0.28, −0.07) | P = .01, I2 = 77% | −0.48 (−0.54, −0.42) | P = .96, I2 = 0% | P < .00001, I2 = 95.6% |
HDL-C | 0.09 (0.01, 0.18) | P = .94, I2 = 0% | −0.12 (−0.19, −0.06) | P = .82, I2 = 0% | P < .0001, I2 = 94.1% |
BMI = body mass index, BW = body weight, HC = hip circumference, HDL-C = high-density lipoprotein cholesterol, LDL-C = low-density lipoprotein cholesterol, TC = total cholesterol, TG = triglyceride, WC = waist circumference.
3.5.3. Subgroup analyses by different treatment times
The number of treatments for subjects varies among the included studies, with 6 studies receiving less than or equal to 30 treatments, 6 studies conducting more than 30 treatments, and 1 study not clearly describing the number of treatments. Subgroup analyses were conducted by different treatment times (treatment times ≤30, treatment times >30). The results showed that no significant differences between subgroups were found in BW (P = .34, I2 = 0%), BMI (P = .16, I2 = 48.9%), WC (P = .76, I2 = 0%), HC (P = .26, I2 = 22.0%), TG (P = .16, I2 = 49.5%), LDL-C (P = .26, I2 = 20.9%), but more significant reduction in TC (P < .00001, I2 = 95.9%) and HDL-C (P < .0001, I2 = 94.1%) for treatment times ≤30 subgroup (Table 6).
Table 6.
Subgroup analyses by different treatment times.
Outcomes | Treatment times ≤ 30 | Treatment times > 30 | Subgroup differences | ||
---|---|---|---|---|---|
MD (95% CI) | Heterogeneity | MD (95% CI) | Heterogeneity | ||
BW | −5.55 (−9.68, −1.42) | P < .0001, I2 = 84% | −3.15 (−5.86, −0.44) | P = .37, I2 = 0% | P = .34, I2 = 0% |
BMI | −3.18 (−4.79, −1.58) | P < .00001, I2 = 96% | −1.82 (−2.86, −0.77) | P = .005, I2 = 70% | P = .16, I2 = 48.9% |
WC | −2.49 (−7.66, 2.67) | P = .0005, I2 = 87% | −3.30 (−4.36, −2.25) | P = .32, I2 = 0% | P = .76, I2 = 0% |
HC | −1.44 (−2.82, −0.05) | P = .30, I2 = 16% | −0.20 (−1.83, 1.43) | Not applicable | P = .26, I2 = 22.0% |
TC | −0.69 (−0.82, −0.57) | P = .94, I2 = 0% | 0.08 (−0.20, 0.36) | P = .25, I2 = 29% | P < .00001, I2 = 95.9% |
TG | −0.65 (−1.45, 0.16) | P = .03, I2 = 80% | −0.06 (−0.20, 0.09) | P = .18, I2 = 41% | P = .16, I2 = 49.5% |
LDL-C | −0.48 (−0.54, −0.42) | P = .96, I2 = 0% | −0.28 (−0.62, 0.06) | P = .01, I2 = 77% | P = .26, I2 = 20.9% |
HDL-C | −0.12 (−0.19, −0.06) | P = .82, I2 = 0% | 0.09 (0.01, 0.18) | P = .94, I2 = 0% | P < .0001, I2 = 94.1% |
BMI = body mass index, BW = body weight, HC = hip circumference, HDL-C = high-density lipoprotein cholesterol, LDL-C = low-density lipoprotein cholesterol, TC = total cholesterol, TG = triglyceride, WC = waist circumference.
4. Discussion
4.1. Principal findings
The systematic review and meta-analysis evaluated the comparative effectiveness of massage combined with lifestyle intervention and lifestyle intervention alone for simple obesity. A total of 848 subjects with simple obesity from 13 RCTs were included. The use of massage combined with lifestyle intervention significantly decreased BW, BMI, WC, TC, TG, LDL-C, FINS, HOMA-IR, but had less effect in increasing HDL-C, compared with lifestyle intervention alone.
BMI is the cornerstone of the current classification system for obesity,[74] but it is actually a measure of height/weight relationships and tells us nothing about the underlying heterogeneity of obesity.[75] While WC is an effective surrogate measure for central or visceral adipose tissue in comparison with BMI, which is an effective measure of total adiposity.[76] HC is a more specific measure of subcutaneous adipose tissue.[76] From this meta-analysis, we found that massage combined with lifestyle intervention not only has a stronger effect in reducing BW and BMI but also has a stronger effect in reducing WC compared with lifestyle intervention alone, which means massage combined with lifestyle intervention is more effective in reducing visceral adipose tissue compared with lifestyle intervention alone.
Usually, obesity is intimately associated with dyslipidemia.[77] Elevated TG, and moderately elevated LDL-C accompanied by decreased HDL-C are the main characteristics of dyslipidemia caused by obesity.[78] In this study, massage combined with lifestyle intervention resulted in more decline on the level of TC, TG, and LDL-C compared with lifestyle intervention alone. Therefore, massage combined with lifestyle intervention has a stronger ability to improve dyslipidemia compared with lifestyle intervention alone. Interestingly, massage combined with lifestyle intervention is not as effective as lifestyle intervention alone in increasing HDL-C, which is worth further exploration.
Overweight/obese is usually associated with enhanced insulin resistance[79] and a heightened risk of diabetes, cardiovascular diseases, and premature mortality.[76,80] Insulin resistance is the main driving force behind the development of dyslipidemia.[77] In this study, compared with lifestyle intervention alone, massage combined with lifestyle intervention also produced more decline on the level of FINS and HOMA-IR, indicating more improvement in insulin resistance.
So, the results of this study showed that massage combined with lifestyle intervention can further improve the effect of lifestyle intervention on obesity. Therefore, in clinical practice, massage can be used in conjunction with lifestyle interventions to manage obesity. As research deepens, massage therapy may be widely used as an evidence-based complementary and alternative therapy for weight loss treatment.
4.2. Implications from subgroup analyses
In subgroup analyses by different ages, more obvious reduction in BMI occurred in the children and adolescents (<18 years) subgroup but more obvious reduction in HC presented in the adults (≥18 years) subgroup. The underlying reason is worth further exploration in the future.
In subgroup analyses by different treatment intervals, more significant reduction was detected in TC, LDL-C, and HDL-C for intermittent treatment subgroup, suggesting a better ability in reducing the levels of TC and LDL-C, but a slightly inferior ability in improving the HDL-C level for intermittent massage therapy compared with continuous massage therapy. That is to say, the effect of continuous massage intervention may not necessarily be better than intermittent massage intervention. Therefore, the optimal treatment interval also needs to be carefully considered in the future.
In subgroup analyses by different treatment times, no significant differences between subgroups were found in BW, BMI, WC, HC, TG, and LDL-C, meaning no sustained improvement in effectiveness as the course of treatment prolongs. However, more significant reduction in TC and less increase in HDL-C occurred in treatment times ≤30 subgroup compared with treatment times >30 subgroup, so, is the effect of massage on blood lipids temporary or has other reasons, which is worth exploring further.
4.3. Strengths of this study
There are 2 obvious strengths to our study. First, this review provides the most comprehensive synthesis of the evidence on massage for weight loss to date. Different from the previous review, we only included RCTs comparing the effectiveness of massage combined with lifestyle intervention and lifestyle intervention alone for simple obesity, making this review the most comprehensive update on the evidence of massage for simple obesity. Second, subgroup analyses were conducted by different ages, different treatment intervals and different treatment times, identifying some detailed issues in clinical practice.
4.4. Limitations of this study
This study has some limitations that should be addressed in future studies. First, among the included trials, a high risk of bias existed because of the lack of sufficient level of blinding. In the included trials, only 4 trials definitely described computer-generated randomization, but none of the 13 trials mentioned the method of blinding. In this review, substantial heterogeneity was observed and contributed to lowering the evidence grade from moderate to very low. Although blinding of subjects and investigators in massage and exercise intervention studies would be difficult, blinding of subjects and outcome assessment should be carried out to minimize the performance and evaluation bias of the studies. Thus, more trials with higher methodology standards should be conducted in the future.
Second, the number of included trials and subjects was small, which may limit statistical power. To obtain more statistically significant results, large samples and multicenter randomized trials should be carried out in days to come.
Third, the duration of massage differed considerably among the different trials. The duration of treatment ranged from 4 weeks to 5 months, and the duration of each intervention ranged from 20 to 60 minutes. The frequency of massage also varied among the studies, including once a day, once every other day, or 2 to 3 times a week with a rest at the weekend. Exercise therapy was also diversified. Despite the subgroup analysis was conducted by different treatment intervals and different treatment times in our meta-analysis, it is difficult to introduce concrete suggestions on the frequency and time of intervention, and the optimal treatment interval and the most appropriate treatment session length still need to be carefully considered in the future.
Fourth, the manipulation and acupoints differed across the included studies, with no unified manipulation and acupoint selection.
Fifth, in this meta-analysis, the language types of literature are limited in Chinese and English with no access to other important foreign language databases, and all of the studies had been conducted in China. In addition, most funnel plots were not feasible owing to the limited number of trials included for each comparison.
Sixth, none of the included trials reported the compliance rate. Low compliance rate is a disadvantage of lifestyle intervention for obesity. If massage combined with lifestyle intervention could improve compliance compared with lifestyle intervention alone, there would be strong evidence to support massage as a means to help lose weight.
Seventh, only 1[69] of the 13 trials reported the follow-up after treatment. The long-term efficacy of massage combined with lifestyle intervention on obesity deserves further attention.
Finally, only 2[63,68] of the 13 trials described adverse events. Understanding the adverse events associated with massage combined with lifestyle intervention for weight loss can better guide clinical practice. Therefore, continuous reporting of adverse events is necessary.
5. Conclusions
The systematic review and meta-analysis showed that the use of massage combined with lifestyle intervention significantly decreased BW, BMI, WC, TC, TG, LDL-C, FINS, and HOMA-IR compared with lifestyle intervention alone, and massage combined with lifestyle intervention is not as effective as lifestyle intervention alone in increasing HDL-C. Subgroup analyses presented age, treatment intervals, and treatment times may also affect treatment outcomes. And, our results highlight the need for research with high quality of trial and high certainty of evidence, and for studies considering different ages, different treatment intervals, and different treatment times.
Acknowledgments
We thank all the authors for their contributions to this systematic review.
Author contributions
Data curation: Gaofeng Wang, Lili Zhang, Lili Chen, Huijuan Lou.
Formal analysis: Gaofeng Wang, Lili Zhang, Lili Chen, Huijuan Lou.
Writing – original draft: Gaofeng Wang, Hongyu Ju.
Conceptualization: Hongyu Ju, Zepeng Zhang, Xingquan Wu, Heli Niu, Yonggang Yang.
Methodology: Zepeng Zhang, Xingquan Wu, Heli Niu, Yonggang Yang.
Writing – review & editing: Zepeng Zhang, Xingquan Wu, Heli Niu, Yonggang Yang.
Supervision: Yonggang Yang.
Abbreviations:
- BMI
- body mass index
- BW
- body weight
- CI
- confidence interval
- CNKI
- China National Knowledge Infrastructure
- FINS
- fasting insulin
- GRADE
- Grading of Recommendations Assessment, Development, and Evaluation
- HC
- hip circumference
- HDL-C
- high-density lipoprotein cholesterol
- HOMA-IR
- homeostasis model assessment–insulin resistance
- LDL-C
- low-density lipoprotein cholesterol
- MD
- mean difference
- RCTs
- randomized controlled trials
- TC
- total cholesterol
- TG
- triglyceride
- WC
- waist circumference
This project was funded by Administration of Traditional Chinese Medicine of Jilin Province (2024355), the key research and development project on Baicheng Glycyrrhiza of Baicheng Medical College (BCGC202419), Natural Science Foundation of Jilin Province (YDZJ202301ZYTS140), and the National Natural Science Foundation of China (grant no. 82274673).
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Supplemental Digital Content is available for this article.
How to cite this article: Wang G, Ju H, Zhang Z, Wu X, Niu H, Zhang L, Chen L, Lou H, Yang Y. Comparative effectiveness of massage combined with lifestyle intervention and lifestyle intervention alone for simple obesity: A systematic review and meta-analysis. Medicine 2025;104:2(e41074).
References
- [1].Schetz M, De Jong A, Deane AM, et al. Obesity in the critically ill: a narrative review. Intensive Care Med. 2019;45:757–69. [DOI] [PubMed] [Google Scholar]
- [2].Sun T, Xie J, Zhu L, Han Z, Xie Y. Left ventricular hypertrophy and asymptomatic cardiac function impairment in Chinese patients with simple obesity using echocardiography. Obes Facts. 2015;8:210–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [3].Kivimäki M, Kuosma E, Ferrie JE, et al. Overweight, obesity, and risk of cardiometabolic multimorbidity: pooled analysis of individual-level data for 120 813 adults from 16 cohort studies from the USA and Europe. Lancet Public Health. 2017;2:e277–85. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [4].Jovic D, Marinkovic J, Vukovic D. Association between body mass index and prevalence of multimorbidity: a cross-sectional study. Public Health. 2016;139:103–11. [DOI] [PubMed] [Google Scholar]
- [5].Frühbeck G, Toplak H, Woodward E, Yumuk V, Maislos M, Oppert J-M; Executive Committee of the European Association for the Study of Obesity. Obesity: the gateway to ill health – an EASO position statement on a rising public health, clinical and scientific challenge in Europe. Obes Facts. 2013;6:117–20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [6].Bagheri R, Rashidlamir A, Ashtary-Larky D, et al. Does green tea extract enhance the anti-inflammatory effects of exercise on fat loss? Br J Clin Pharmacol. 2020;86:753–62. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [7].Durrer Schutz D, Busetto L, Dicker D, et al. European practical and patient-centred guidelines for adult obesity management in primary care. Obes Facts. 2019;12:40–66. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [8].Znyk M, Zajdel R, Kaleta D. Consulting obese and overweight patients for nutrition and physical activity in primary healthcare in Poland. Int J Environ Res Public Health. 2022;19:7694. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [9].Heymsfield SB, Wadden TA. Mechanisms, pathophysiology, and management of obesity. N Engl J Med. 2017;376:254–66. [DOI] [PubMed] [Google Scholar]
- [10].American College of Cardiology/American Heart Association Task Force on Practice Guidelines, Obesity Expert Panel, 2013. Expert Panel Report: Guidelines (2013) for the management of overweight and obesity in adults. Obesity (Silver Spring). 2014;22(Suppl 2):S41–410. [DOI] [PubMed] [Google Scholar]
- [11].Wadden TA, West DS, Delahanty L, et al.; Look AHEAD Research Group. The Look AHEAD study: a description of the lifestyle intervention and the evidence supporting it. Obesity (Silver Spring). 2006;14:737–52. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [12].Blüher M. Obesity: global epidemiology and pathogenesis. Nat Rev Endocrinol. 2019;15:288–98. [DOI] [PubMed] [Google Scholar]
- [13].Daousi C, Casson IF, Gill GV, MacFarlane IA, Wilding JPH, Pinkney JH. Prevalence of obesity in type 2 diabetes in secondary care: association with cardiovascular risk factors. Postgrad Med J. 2006;82:280–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [14].Ross SA, Dzida G, Vora J, Khunti K, Kaiser M, Ligthelm RJ. Impact of weight gain on outcomes in type 2 diabetes. Curr Med Res Opin. 2011;27:1431–8. [DOI] [PubMed] [Google Scholar]
- [15].Bertisch SM, Wee CC, McCarthy EP. Use of complementary and alternative therapies by overweight and obese adults. Obesity (Silver Spring). 2008;16:1610–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [16].Steyer TE, Ables A. Complementary and alternative therapies for weight loss. Prim Care. 2009;36:395–406. [DOI] [PubMed] [Google Scholar]
- [17].Allison DB, Fontaine KR, Heshka S, Mentore JL, Heymsfield SB. Alternative treatments for weight loss: a critical review. Crit Rev Food Sci Nutr. 2001;41:1–28; discussion 39. [DOI] [PubMed] [Google Scholar]
- [18].Ersek RA, Mann GE, Salisbury S, Salisbury AV. Noninvasive mechanical body contouring: a preliminary clinical outcome study. Aesthetic Plast Surg. 1997;21:61–7. [DOI] [PubMed] [Google Scholar]
- [19].Chang P, Wiseman J, Jacoby T, Salisbury AV, Ersek RA. Noninvasive mechanical body contouring: (Endermologie) a one-year clinical outcome study update. Aesthetic Plast Surg. 1998;22:145–53. [DOI] [PubMed] [Google Scholar]
- [20].DeMaria A, DeMaria C, Demaria R, Alcantara J. A weight loss program in a chiropractic practice: a retrospective analysis. Complement Ther Clin Pract. 2014;20:125–9. [DOI] [PubMed] [Google Scholar]
- [21].Benelli L, Berta JL, Cannistra C, Amram P, Benhamou G. Endermologie: humoral repercussions and estrogen interaction. Aesthetic Plast Surg. 1999;23:312–5. [DOI] [PubMed] [Google Scholar]
- [22].Güleç AT. Treatment of cellulite with LPG endermologie. Int J Dermatol. 2009;48:265–70. [DOI] [PubMed] [Google Scholar]
- [23].Foster KW, Kouba DJ, Hayes J, Freeman V, Moy RL. Reductions in thigh and infraumbilical circumference following treatment with a novel device combining ultrasound, suction, and massage. J Drugs Dermatol. 2008;7:113–5. [PubMed] [Google Scholar]
- [24].Brightman L, Weiss E, Chapas AM, et al. Improvement in arm and post-partum abdominal and flank subcutaneous fat deposits and skin laxity using a bipolar radiofrequency, infrared, vacuum and mechanical massage device. Lasers Surg Med. 2009;41:791–8. [DOI] [PubMed] [Google Scholar]
- [25].Boey GE, Wasilenchuk JL. Enhanced clinical outcome with manual massage following cryolipolysis treatment: a 4-month study of safety and efficacy. Lasers Surg Med. 2014;46:20–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [26].Lee KJ, Park JI, Oh SY. The effects of extracorporeal shock wave therapy vs hand massage on serum lipids in overweight and obese women. Ann Med Surg (Lond). 2021;63. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [27].Antoniak K, Zorena K, Hansdorfer-Korzon R, Wojtowicz D, Koziński M. Favourable changes in C-peptide, C-reactive protein and lipid profile, and improved quality of life in patients with abnormal body mass index after the use of manual lymphatic drainage: a case series with three-month follow-up. Medicina (Kaunas). 2022;58:273. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [28].Donoyama N, Suoh S, Ohkoshi N. Adiponectin increase in mildly obese women after massage treatment. J Altern Complement Med. 2018;24:741–2. [DOI] [PubMed] [Google Scholar]
- [29].Ernst E. Acupuncture/acupressure for weight reduction? A systematic review. Wien Klin Wochenschr. 1997;109:60–2. [PubMed] [Google Scholar]
- [30].Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [31].Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [32].Guyatt GH, Oxman AD, Vist GE, et al.; GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336:924–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [33].Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–60. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [34].Takkouche B, Khudyakov P, Costa-Bouzas J, Spiegelman D. Confidence intervals for heterogeneity measures in meta-analysis. Am J Epidemiol. 2013;178:993–1004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [35].Melsen WG, Bootsma MCJ, Rovers MM, Bonten MJM. The effects of clinical and statistical heterogeneity on the predictive values of results from meta-analyses. Clin Microbiol Infect. 2014;20:123–9. [DOI] [PubMed] [Google Scholar]
- [36].Gelber RD, Goldhirsch A. Meta-analysis in clinical research. Ann Intern Med. 1988;108:158–9. [DOI] [PubMed] [Google Scholar]
- [37].Ades AE, Lu G, Higgins JP. The interpretation of random-effects meta-analysis in decision models. Med Decis Making. 2005;25:646–54. [DOI] [PubMed] [Google Scholar]
- [38].Sterne JA, Sutton AJ, Ioannidis JPA, et al. Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials. BMJ. 2011;343:d4002. [DOI] [PubMed] [Google Scholar]
- [39].Chen S, Li L, Li H. Effect of massage in traditional Chinese medicine on short penis in male obese children. Chin J Clin Rehabil. 2006;10:168–9. [Google Scholar]
- [40].Wu W, Lei M. Study on TCM intervention methods of overweight and obesity in secondary vocational school students. Lishizhen Med Mater Med. 2012;23:1689–90. [Google Scholar]
- [41].Zhang J, Huang J, Cui S. Study on comprehensive intervention measures for childhood obesity. Guangdong Med J. 2007;28:1502–4. [Google Scholar]
- [42].Cheng J, et al. Effect of massage combined exercise on body mass index and body fat rate of overweight college students. World Latest Med Inf (Electron Version). 2019;19:190,192. [Google Scholar]
- [43].Jia X. Observation on the therapeutic effect of massage on 30 cases of simple obesity. Chin Manipulation Qi Gong Ther. 2003:19–20. [Google Scholar]
- [44].Jiang S. Research on the effect of aerobic exercise and acupoint massage on the body shape of obese women. Sports World. 2014:131–2. [Google Scholar]
- [45].Li H, Luo X, Wang M. Effect of weight loss on glucose tolerance and insulin secretion in simple obese children. Chin J Appl Clin Pediatr. 2005;20:520–1. [Google Scholar]
- [46].Li H, Ju W, Li L, Luo X, Wang M. Epidemiological investigation of child simple obesity in Zhengzhou area and intervention research on massage along channel of traditional Chinese medicine. Chin J Appl Clin Pediatr. 2005;20:1260–2. [Google Scholar]
- [47].Wang C. Research on the methods of male college students’ weight loss and body shaping. Neijiang Technol. 2011;32:70. [Google Scholar]
- [48].Wang X, et al. A study on the effect of massage on body abdominal fat loss. Sport Sci Technol. 2021;42:15–6. [Google Scholar]
- [49].Xie Y, et al. Clinical study on 106 cases of simple obesity treated with massage. Chin Manipulation Qi Gong Ther. 2002;18:5. [Google Scholar]
- [50].Zhang B, et al. 44 Cases of weight loss by massaging Guanyuan point. Chin Acupunct Moxibustion. 1985:24. [Google Scholar]
- [51].Zhang S. Effect of exercise combined with massage on weight loss in obese adolescents. China Health Ind. 2016;13:68–70. [Google Scholar]
- [52].Zhuo Y, et al. Clinical observation on 26 cases of simple obesity in children treated by massage with the method of activating the spleen and removing turbidity. Matern Child Health Care China. 2013;28:4405–6. [Google Scholar]
- [53].Guo Q. Study on the effect of exercise combined with massage on weight loss of severely obese adolescents. Diet Health Care. 2018;5:66–7. [Google Scholar]
- [54].Xu S. Preliminary study on the effect of aerobic exercise combined with local massage on weight loss. Guide Sci Educ. 2017:118–9. [Google Scholar]
- [55].Li W, Juan Y, Min Y. Effect in massage therapy of invigorating spleen and removing damp on comprehensive symptoms and signs of simple obesity patients. Chin Manipulation Rehabil Med. 2015;6:30–1. [Google Scholar]
- [56].Jiang R, et al. Effect of massage of spleen stomach meridian on postpartum obesity. Clin J Chin Med. 2020;12:25–8. [Google Scholar]
- [57].Luo L, Liu J. Clinical study on massage to reduce postpartum obesity. Chin Manipulation Rehabil. 2011;2:6–7. [Google Scholar]
- [58].Wang Q, et al. Effect of massage of spleen stomach meridian on blood lipid and waist hip ratio in postpartum obese patients. China Health Care Nutr. 2020;30:18–9. [Google Scholar]
- [59].Zhang X, et al. Effect of the massage method of “Yun Fu Tong Jing” on the expression of leptin resistance and inflammatory factors in aged women with abdominal obesity. Chin J Gerontol. 2022;42:3965–7. [Google Scholar]
- [60].Zhu J, et al. Observation on the therapeutic effect of meridian regulation on perimenopausal central obesity. Zhejiang Clin Med J. 2021;23:1439–41. [Google Scholar]
- [61].Benling W, Juan Y. Clinical observation on the change of blood lipid in simple obesity treated by invigorating spleen and removing dampness massage. Jilin J Tradit Chin Med. 2010;30:786–8. [Google Scholar]
- [62].Bohua Y, et al. The effect of meridian massage on BM, BMI, WC and HC in simple obesity patients: a randomized controlled trial. World J Acupunct Moxibustion. 2014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [63].Fengyan L, et al. Efficacy of acupoint massage for auxiliarily treating pediatric simple obesity. Guangxi Med J. 2019;41:698–701,705. [Google Scholar]
- [64].Huimei L, Juan Y. Clinical observation on 67 cases of simple obesity of spleen deficiency and dampness resistance treated by massage. J Shandong Univ Tradit Chin Med. 2010;34:508–9. [Google Scholar]
- [65].Yin G, Peijie C, Wenhe C. Research on weight loss effect by exercise combined with massage on severe obese adolescents. J Shanghai Univ Sport. 2011;35:70–73+94. [Google Scholar]
- [66].Yanpeng N. Clinical study on massage in treating simple obesity. Diet Health Care. 2017;4:101–2. [Google Scholar]
- [67].Yuan W. Effect analysis of massage on insulin resistance of simple obese children. Smart Healthcare. 2021;7:146–8. [Google Scholar]
- [68].Xiantao T, Lei X. Clinical study on the treatment of simple obesity in children with weight-loss massage cream. J Yunnan Coll Tradit Chin Med. 2006;29:29–32. [Google Scholar]
- [69].Hongling L, et al. Treatment of simple obesity in children with massage along meridians of traditional Chinese medicine and behavior education. Chin J Clin Rehabil. 2003;7:2237. [Google Scholar]
- [70].Yuehong Z, Wei J. Clinical observation of traditional Chinese massage on insulin resistance in simple obese children. Guangming J Chin Med. 2015;30:1945–7. [Google Scholar]
- [71].Shengce J. Effects of aerobic exercise and acupoint massage on body composition and blood lipid level in obese women. J Changchun Normal Univ (Nat Sci). 2014:98–101. [Google Scholar]
- [72].Wei J, Yuehong Z. Clinical observation on the effect of Chinese massage on blood lipid and sex hormones in simple obese children. China’s Naturopathy. 2015;23:19–21. [Google Scholar]
- [73].Hongyan L, et al. Observation on the effect of exercise combined with massage on weight loss of severely obese adolescents. Special Health. 2022:17–8. [Google Scholar]
- [74].Prentice AM, Jebb SA. Beyond body mass index. Obes Rev. 2001;2:141–7. [DOI] [PubMed] [Google Scholar]
- [75].Bray GA. Beyond BMI. Nutrients. 2023;15:2254. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [76].Cameron AJ, Magliano DJ, Söderberg S. A systematic review of the impact of including both waist and hip circumference in risk models for cardiovascular diseases, diabetes and mortality. Obes Rev. 2013;14:86–94. [DOI] [PubMed] [Google Scholar]
- [77].Vekic J, Zeljkovic A, Stefanovic A, Jelic-Ivanovic Z, Spasojevic-Kalimanovska V. Obesity and dyslipidemia. Metabolism. 2019;92:71–81. [DOI] [PubMed] [Google Scholar]
- [78].Otvos JD, Mora S, Shalaurova I, Greenland P, Mackey RH, Goff DC. Clinical implications of discordance between low-density lipoprotein cholesterol and particle number. J Clin Lipidol. 2011;5:105–13. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [79].Lin Y, Bai M, Wang S, et al. Lactate is a key mediator that links obesity to insulin resistance via modulating cytokine production from adipose tissue. Diabetes. 2022;71:637–52. [DOI] [PubMed] [Google Scholar]
- [80].Pi-Sunyer X, Blackburn G, Brancati FL, et al.; Look AHEAD Research Group. Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the look AHEAD trial. Diabetes Care. 2007;30:1374–83. [DOI] [PMC free article] [PubMed] [Google Scholar]