ACUPUNCTURE TREATMENT INTEGRATED HEADSET IN OBESITY
Obesity: epidemic of the third millennium

Obesity is the most common chronic disease of the Western world. There are about 300 million obese in the world, an epidemic for which has been coined the Anglo-Saxon neologism "globesity" well that makes the idea of the phenomenon. It is a complex disease due to genetic, environmental and individual, that determine a change in the energy balance, resulting in increased body weight caused by excessive accumulation of adipose tissue in the body. Weight gain can be realized only if there is a positive balance between calorie intake and energy consumption, due to a condition of overeating associated with reduced physical activity. These conditions are typical of the lifestyle of the industrialized countries, where the abundance of food is accompanied by a lifestyle that will gradually but surely reduce the chances of movement. (D'Amicis A et al., 2006)
The treatment of obesity and the paradox of the diet

The therapeutic approach to the problem of obesity has always been largely prescriptive, aimed at weight loss by decreasing calorie intake (dietary restriction). In the natural history of the obese subject, at least in the early stages of treatment, weight loss is an event relatively easy to reach, whatever the type of applied diet. Problems arise in prolonged treatment, particularly in long-term maintenance of weight lost. As I described in a now classic study of 1959 by Stunkard and McLaren 2/3 of people who lose weight regain it within one year and after five years most dieters undergo patients recover the initial weight. (Stunkard AJ et al., 1959) The caloric restriction is for the organism a stressful situation, with the activation of a complex neuro-endocrine-metabolic chain, followed by a number of alarm signals indicating the need of energy. iI most important is represented by the feeling of hunger. You can have psychoemotive changes such as anxiety, hostility, anger, irritability, low mood, often associated with episodes of craving and binge eating. In this situation of precarious balance, the loss of control on caloric restriction is an event all the more likely, especially in situations of particular emotional commitment. In the remainder of dietary restriction, the defaillance episodes multiply and often the patient definitively abandoned their therapist (eclipse phenomenon). During this period, which is absent any form of dietary control, weight inevitably increases, often exceeding the initial one, configuring the so-called Weight Cycling Syndrome. And 'now unanimously it accepted that repeated caloric restrictions, and the consequent weight fluctuation cycles, involving a gradual increase in weight. Paradoxically, it could be argued that "diets lead to obesity." (Bosello O et al., 1998) The international scientific community is now agrees that no prescription (dietoterapica and / or pharmacological) has, by itself, the ability to permanently reduce weight in obese subject, if at the same time is not changed the dietary behavior and lifestyle. (Melchionda N, 1996) Recent studies show that dietary restriction, if not supported by an adequate psychological support, pharmacotherapy, and why not, acupuncture, seems to be doomed to failure.

Integrated treatment of obesity and the role of Acupuncture Headset

Our study group has defined over time DIMANAT method, which involves the use of auricular stimulation in the integrated treatment of obesity; the first results were communicated as early as World Congress of Auriculotherapy of Lyon in 2000. (Bazzoni G, 2000). The operational guidelines of this method include that the Acupuncture Headset can become an integral part of an "eclectic or integrated model" applicable both in the initial phase of weight loss in the no less important to the maintenance of the lost weight. Despite their limitations of each schematisation this method may be presented using a few essential points, each of which will be discussed based on the data available in the literature, integrated with personal clinical experience and research.

The 1st Stimulation Headset (Headset Acupuncture - Auricular therapy) is able to facilitate, subject overweight and / or obese, weight loss is that the maintenance of achieved weight (efficacy trials). This is because it acts:

2nd - on eating behavior by improving the "compliance" to caloric restriction.

3rd - metabolism and energy consumption.

Despite their limitations of each schematisation this method may be presented using a few essential points, each of which will be discussed based on the data available in the literature, integrated with personal clinical experience and research.

PACING HEADSET AND EATING BEHAVIOUR

    Satiety
    Adipostato hypothalamic
    emotional hunger
    psychological effects of diet restriction
    (Anxiety, mood, irritability / aggression)
    Binge Eating and Craving
    Modulation of stress response

COMPLIANCE TO DIETARY RESTRICTIONS
Point 1st headset stimulation and obesity: evidence of effectiveness

Between the mid-seventies and early eighties they were published the first work on the applicability of Acupuncture Headset (Auriculotherapy) in the treatment of obesity. It was mostly of "uncontrolled studies", published in the Chinese language, which generally reported significantly positive results with regard to the weight loss. These studies, although burdened with different bias, have provided a useful starting point for further research. The numerous works that have followed over time until today, until the most recent and comprehensive systematic review and metanalitica published by Cho in 2009, seem to indicate good efficacy of therapy in aiding weight loss of obese subject. These authors also underlined the need to proceed with higher quality studies to better validate this particular application auricular acupuncture (SH Cho et al., 2009).
Point 2 Action on eating behavior: improves "compliance" to caloric restriction

a) Modulation of biological sensations of hunger and satiety

b) Speaking on Emotional Eating, of dysfunctional behaviors such as food cravings and binge eating, often present in obese patients. Acting on psychoemotive aspects that accompany the calorie restriction

A) Modulation of biological hunger and satiety signals. Hunger and satiety, real semaphores to food intake, are the result of a complex control system that continuously processes a significant amount of exogenous and endogenous signals, neural, metabolic and endocrine. (Rigamonti AE et al., 2006) The rule satiety the interval between one meal and another, and the frequency of the same. Clinical studies but also the same basic research on the animal, seem to indicate that auricular stimulation is capable of modulating the biological signal of satiety, thus promoting weight loss. This is in its clinical rationale in the fact that most of the obese individuals have a substantial difficulty in proving the feeling of satiety, leading to hyperphagia. The auricular acupuncture can then join in a therapeutic context slimming, aimed education of the patient, and the recognition and subsequent control of hunger and satiety sensations. The DIMANAT study group showed, in subjects undergoing therapy headset, a close correlation between weight loss and proven satiety sensation at different times of the day. (Loi V et al., 2009) The neurobiological mechanisms of hunger and satiety control due to the auricular stimulation have been investigated by several works that have allowed to distinguish two levels of control: central and peripheral.

- Stimulation headset and control "center" of the biological signals of hunger and satiety. In 1992 the Japanese neurophysiologist Asamoto has shown that the stimulation with needles of the valley regions of the rat was able to evoke the potential to level the ventromedial hypothalamus (VMN). At the same time the animal reduced food intake losing weight. This work has provided a first theoretical explanatory model applicability of auricular stimulation in obese patient. Asamoto S et al., 1992) The action of the hypothalamus neuromodulante auricular stimulation has been confirmed by other researchers (T Shiraishi T et al., 1995) (Zhao M et al., 2000). In 2001, the Korean Kim has shown that the stimulation with needles of the ear is capable of reducing the hypothalamic NPY expression in fasted rats, suggesting the existence of another neurobiological mechanism that stimulation headset may in turn modulate clinically hunger and satiety. . (Kim EH, 2001)

- Headset and control Stimulation "peripheral" biological signals of hunger and satiety The feeling of satiety receives a further control by metabolic signals, endocrine and nervous originated at peripheral level. It 'worth remembering that the innervation of the pavilion is basically under the control of the nerves Big headset (cervical plexus C2-C3), auricolo-Temporal (III Trigeminal branch) and Headset (N. Vago). (Rabishong P, 2010) It has been hypothesized that auricular therapy, stimulating just this vagal component (of the basin region), determines interference on peripheral signals from the gastrointestinal tract, leading to an increase in satiety and inhibition of hunger. (D Richards et al., 1998) The American Choy, subject to special clips ear sull'Hunger Point tragal, achieved a significant lengthening of the GPT (Gastric Peristalsis Time). It can be assumed that precisely this phenomenon is one of the mechanisms responsible for the more rapid onset and the maintenance in the time of the feeling of satiety, obtainable with auricular stimulation. (Choy DS et al. 1998) are based on this principle newer forms of self stimulation dell'Hunger point tragal practiced by an original magneto-pressure headset system. (Manca G, 2009)

B) The auricular stimulation acts positively on the mental and emotional aspects that accompany obesity or that arise when you are on a diet. And 'now unanimously it agreed that there is a very close relationship between eating habits, emotional states, stress and dietary restriction. The fundamental role that emotions have in determining and maintaining dysfunctional eating behaviors, led to the spread of a term such as "Emotional Eating" or "emotional hunger" indicating the use of food, not as a response to a biological stimulus, but in relation to emotional and interpersonal problems. (Geliebter A et al., 2003) The emotional hunger gives a special coloring to the eating behavior of obese patients, making it difficult to follow any dietary restrictions. It can take the form of "compulsive hunger" present in eating disorders (DCA): Anorexia and Bulimia), Binge Eating Disorders (BED), Night Eating Syndrome. recurrent episodes of compulsive overeating (binge eating), Craving for food (food craving), Grignottage (nibbling small amounts of food), despite the absence of real DCA, are present in obese subjects.

(E Mannucci et al., 2001)

Several papers have studied the close links between stress, obesity and dietary restriction. Obese people under stress tend to eat more than their habits, while the normal weight are usually the opposite. The follow a diet, especially if it is very restrictive, is interpreted by the body as a stressful situation, is a relevant factor in the genesis of abnormal eating behaviors, capable of determining a return to previous eating habits. (Rosen JC et al., 1993) The action of modulating the stimulation headset on emotional hunger and related dysfunctional behaviors (binge eating, Food Craving, Grignottage), details were psychoemotive that often accompany a diet, was confirmed, not only clinical experience of our study group, but also in the work of other researchers.

(Marucci S, 2009)

This particular application is its clinical rational actions: anti-anxiety, mood-control, optimization of the stress response, the control of the drives, therapeutic action on which there is now a large literature. The neurobiological basis of this therapeutic model are closely linked to the modulation carried on complex brain neurochemical systems of controlling emotions, motivation and gratification of stress mechanisms, acting on feeding behavior. (GABAergic, serotonergic, noradrenergic, dopaminergic, Endogenous Opioid, NPYergico, Neuroendocrine Stress). (Napadow V et al., 2006).
Action point 3 ° of metabolism and energy consumption.

Among other possible mechanisms, invoked to explain the action of the auricular stimulation in promoting weight loss, there are those on thermogenesis and metabolism. A key role is played by NPY. In addition to the action oressigena this neuro-peptide reduces reduces the metabolism and energy expenditure, with the mediation of the NPY receptor 1 (Billington CJ et al., 1991) It 'important to note that the NPY is released, not only in shortages food (not desired or suffered by the individual, as in the case of a famine, or in the case of autoprocurata and voluntary deficiency due to diet), but also in situations of stress. (Kuo LE et al., 2007) The Stimulation Headset has proven effective in reducing the hypothalamic expression of NPY. This mechanism may explain the activation of the energy expenditure and the adjustment to a level below the set point of the weight and energy. (Kim EH et al., 2001) Recently, Shen and colleagues hypothesized that the weight loss achieved on a group of patients using the headset stimulation can be attributed not only to a decrease in appetite, but also to a transient increase in metabolism baseline.

(EY Shen et al., 2009)

CLINICAL EXPERIENCE

Clinical observations than a decade on a sample of over 1,500 overweight and obese patients, supplemented with a detailed literature review work, have enabled us to develop a theoretical and operational model for the application of Acupuncture Headset in the obese patient therapy. The method defined "DIMANAT® - Lose Weight Naturally" provides for the integration of:

- Stimulation HEADSET

- The FOOD EDUCATION PROGRAM

- Of ACTIVITY 'PHYSICAL PROGRAM

The method is aimed initially to weight loss and subsequently to the maintenance of the same during the control phase. The action of the Stimulation Headset acts primarily on feeding behavior of the obese patient and only secondarily on metabolism and energy consumption. (Fig 1) From our experience shows that the headset therapy can be applied on the overweight and obese patient with different purposes depending on the type or of the phases of the dieto-therapeutic program in place and the presence or absence of DCA

A) In the first period of treatment (1-3 months). Objective: improve the adhesion to the caloric restriction. This phase is reserved for those patients who have already tried to lose weight but he failed and / or obese patients with a diagnosis of BED in combination with appropriate psycho-educational intervention and cognitive behavioral psychotherapy (CBT).

B) In the second phase (3 to 6-12 months). It corresponds to the slowdown of slimming, per share of homeostatic mechanisms that active body in an attempt to bring the body weight to the values prior to weight loss. Objective: To maintain adherence to dietary restriction in place, reducing the phenomenon of relapse.

C) At the end of the weight loss period, however obtained. Goal: to prevent the recovery of short-term weight lost, (12-24 months), as established in 1995 by '' Institute of Medicine of the National Academy of Sciences "(weight decrease by at least 5% and maintained for at least 1 year.) (from the grave R, 2004) D) in association with very low calorie diets (Very Low calorie diets - VLCD) in patients with severe obesity (grade II), BMI between 35 to 39.9 and severe obesity ( III), BMI equal to or greater than 40.

(Armellini F et al., 1998)

Objective: improve the adhesion to the dietary restriction, support the maintenance of the lost weight.

CLINICAL EXPERIENCE

a) In the first period of treatment (1-3 months) Objective: To improve adhesion to the caloric restriction. This phase is reserved for patients who have already tried unsuccessfully to weight loss and / or obese patients with a diagnosis of BED in combination with appropriate psycho-educational intervention and cognitive behavioral psychotherapy (CBT). b) Second Phase (3 to 6-12 months) This corresponds to slowing of weight loss, per share of homeostatic mechanisms that active body in an attempt to bring the body weight to the values prior to weight loss. Objective: To maintain adherence to dietary restriction in place, reducing the phenomenon of relapse. c) Third Step (12 - 24 months) At the end of the weight loss period, however obtained. Goal: to prevent the recovery of short-term weight lost, as established in 1995 by '' Institute of Medicine of the National Academy of Sciences "(weight decrease by at least 5% and maintained for at least one year.) D) Fourth Stage in association with very low calorie diets (Very Low calorie diets - VLCD) in patients with severe obesity (grade II), BMI between 35 to 39.9 and severe obesity (grade III), BMI greater than or equal to 40. Objective : improve adherence to dietary restriction and support the maintenance of the lost weight.

METHOD

The method provides stimulation continues in time of 6/7 acupoints earphones identified in the framework of a group of 13. (Fig 2) The acupoints are grouped together to form "therapeutic sets" primary and secondary, capable of acting on the various aspects eating behavior. Acupoints earphones are then stimulated with small metal spheres, Vaccaria seeds, needles semipermanenza left in place for a period of 7 to 28 days, as determined by the therapist in relation to the different phases of the program that the patient is taking, and the results obtained. At first (1993-1998) have been used needles to semipermanenza (ASP Sedatelec-France), subsequently magnetic beads from 100 Gauss (1998-2001) and in the last magnetic beads to 800 Gauss. In subjects allergic to the metal have been applied Vaccaria seeds. Currently particularly used are the microneedles type Pyonex (0.3 - 0.6 - 0.9 mm in length) of the Japanese company Seirin. The protocol begins with the administration set Therapeutic Primary applied according to the dominant laterality of the patient. The 2nd session takes place after seven days stimulating the contralateral pavilion. In some patients it is possible to practice therapy indifferently on both pavilions, alternating the side of stimulation. In contrast, in other proves responsive only the pavilion of one side. The therapy continues with sessions at regular intervals of 21- 30 days. At first (1993-1998) have been used needles to semipermanenza (ASP Sedatelec-France), subsequently magnetic beads from 100 Gauss (1998-2001) and in the last magnetic beads to 800 Gauss. In subjects allergic to the metal have been applied Vaccaria seeds. Currently particularly used are the microneedles of Pyonex type (0.3 - 0.6

- 0.9 mm in length) of the Japanese company Seirin. The protocol begins with the administration set Therapeutic Primary applied according to the dominant laterality of the patient. The 2nd seat is made after seven days stimulating the contralateral pavilion. In some patients it is possible to practice therapy indifferently on both pavilions, alternating the side of stimulation. In contrast, in other proves responsive only the pavilion of one side. The therapy continues with sessions at intervals of 21- 30 days. In the remainder of the therapy, the maintenance phase can be practiced using a magnetopressione headset system (Zeroplus), in this case is the same patient who applies on well defined areas of the pavilion the presser magnete-, according to a precise temporal pattern defined by the therapist (Cronostimolazione headset). The choice of points is driven by an algorithm based on the information provided to the therapist from the same patient that compiles several self-assessment tools in eating behavior and psycho-emotional state. And 'it is validated a dedicated software that can help the therapist and the patient in the application of the method. The DIMANAT ® evaluation board includes two parts, the first (A board) integrates the classic food diary with that of physical activity. The second (card B) includes different tools for assessment of the patient's eating behavior. To assess the subjective feeling of satiety at different times of the day we used a unipolar scale without subdivision (VAS Visual Analogue Scale). With regard to the phenomenon of "Food Craving", waiting for validation in Italian language of "Food Craving Inventory," we have used, also in this case, an SEA, applied to one of the 4 categories, indicated by the same patient, in which They have classified the different types of object of craving food. The card itself provides information about the patient's psycho-emotional state (Anxiety, Mood, Hostility / Aggression / Anger). Feeding behavior Binge Eating is instead evaluated by administration dellaBinge Eating Scale (BES), in the Italian version. This scale can be used for screening of uncontrolled eating disorder, but can also be useful in the assessment of response to treatment. (G Bazzoni, 2009)

LITERATURE REFERENCES

D'Amicis A, Panetta V, L Gargiulo, Adam D, P Vittori (2006) Epidemiology of obesity. Recent data and neuro-psychological disorders associated In: Institute Auxologico Italian 6th report on obesity in Italy. Franco Angeli, Milan Stunkard AJ, Mc Laren Hume-M (1959) The results of treatment for obesity. Arch Intern Med 103: 79-85 Bosello O, Bissoli L (1998) The fluctuation of body weight (Weight Cycling Syndrome) In: Bosello O (Eds) Obesity. A multidimensional Treaty. Editrice Kurtis srl, Milan Melchionda N (1996) Evolution of Obesity therapy. Management in the short and long term multi-dimensional. Edizioni Pendragon, Bologna Bazzoni G (2000) The intervention of the Auriculothérapie dans l'obésité et le controle du comportement alimentaire In: Abstracts of International IIIèmeSymposium Auriculothèrapie et Auriculomédicine Lyon 2000. Cho SH, Lee JS, Thabane L (2009) Acupuncture for obesity: a systematic review and meta-analysis. Int J Obesity for 33 (2): 183-96 Rigamonti AE, EE Muller (2006) Brain and obesity: neurobiology and neuropharmacology In: Institute Auxologico Italian 6th report on obesity in Italy. Franco Angeli, Milan Loi V, Meconcelli G, Let us I (2009) auricular acupuncture in the integrated treatment of overweight: clinical experience. In: Proceedings XXIII Congress S.I.R.A.A. Ed. SIRAA, Spoleto Asamoto S, Takeshige C (1992) Activation of the satiety center by auricular acupuncture point stimulation. Brain Res Bull 29 (2): 157-64 Zhao M, Liu Z, Su J (2000) The time-effect relationship of central action in acupuncture treatment for weight reduction. J Tradit Chin Med 20: 26-29 Shiraishi T, Onoe M, Kojima T et al. (1995) Effects of auricular stimulation on feeding-related hypothalamic neuronal activity in normal and obese rats. Brain Res Bull 36 (2): 141-8 Rabishong P (2010) Anatomy, Embryology and neurophisiology In: Romoli M (Eds) Auricular Acupuncture Diagnosis. Churchill Livingstone Elsevier Richards D, Marley J (1998) Stimulation of auricular acupuncture points in weight loss. Aust Fam Physician 27 Suppl 2: 73-7 S Choy DS, Eidenschenk E (1998) Effect of tragus clips on gastric peristalsis: a pilot study. J Altern Complement Med 4 (4): 399-403 Manca G (2009) Magnetopressione headset and improved compliance to dietary restriction in the patient with excess weight - Thesis Biennale Acupuncture Headset Course Ed. GSATN Geliebter A, Aversa A (2003) Emotional eating in overweight, normal weight, and underweight individuals. Eat Behav 3 (49: 341-7 Mannucci E, Rich V, Wheel CM (2001) Eating behavior in obesity. Pathophysiology and Clinical. Edra srl, Milan Rosen JC, Compas BE, Tacy B (1993) The relation among stress , psychological symptoms, and eating disorder symptoms: a prospective analysis. Int J Disord Sep; 14 (2): 153-62 Marucci S (2009) Auriculotherapy in compulsive hunger. Natural Medicine 3/2009 Napadow V, Webb JM, Pearson N, Hammerschlag R (2006) Neurobiological Correlates of Acupuncture The Journal of Alternative and Complementary Medicine 12 (9): 931-935 Billington JC, Briggs JE, Grace M, Levine AS (1991) Effects of intracerebroventricular injection of neuropeptide Y on Energy metabolism. Am J Physiol 260: R321-7 Kuo LE, Kitlinska JB, Tilan JU, Li L, Baker SB, Johnson MD, EW Lee, Burnett MS, Fricke ST, Kvetnansky R, Herzog H, Zukowska Z (2007) Neuropeptide Y acts directly in the periphery on fat tissue and mediates stress-induced obesity and metabolic syndrome. Nat Med 13.803 to 81 Kim EH, Kim Y, Jang MH et al (2001) Auricular acupuncture decreases neuropeptide Y expression in the hypothalamus of food-deprived Sprague-Dawley rats . Neurosci Lett 13; 307 (2): 113-6 Shen EY, Hsieh CL, Chang YH, Lin JG (2009) Observation of sympathomimetic effect of ear acupuncture stimulation for body weight reduction. Am J Chin Med 37 (6): 1023-30 R From the Grave (2004) Losing and maintaining weight. A new cognitive behavioral program. Positive Press, Verona Armellini F, Weber U, Bissoli L (1998) The highly Low-energy diets (VLED) In: Bosello O (Eds) Obesity. A multidimensional Treaty. Editrice Kurtis srl, Milan Bazzoni G (2009) Knowing the Auriculotherapy. editions