The protocol for this umbrella review was registered with the Open Science Framework (OSF)¹ to ensure transparency and reproducibility. The review was conducted in accordance with the PRISMA 2020 statement and the PRISMA Extension for Umbrella Reviews.

We included systematic reviews and meta-analyses that met the following criteria:

Population: Children and adolescents (<19 years) with simple obesity or overweight. Children and adolescents <19 years were included, consistent with the WHO definition of adolescence (10–19 years) and common practice in pediatric obesity research (11). Reviews focusing exclusively on adults were excluded.

Interventions: Any form of Traditional Chinese Medicine (TCM) intervention, including but not limited to herbal medicine, acupuncture, moxibustion, acupressure, massage (chuna/tuina), cupping, qigong, tai chi, or dietary therapy.

Comparators: Conventional management (diet, exercise, psychological interventions), placebo, Western medicine, or other TCM modalities.

Outcomes: Anthropometric measures (BMI, body weight, waist/hip circumference, body fat), metabolic indicators (lipids, glucose, leptin), TCM syndrome scores, quality of life, and adverse events.

Study design: Systematic reviews and meta-analyses of randomized controlled trials (RCTs) or controlled clinical trials. Narrative reviews, scoping reviews, or reviews of in vitro or animal studies were excluded.

Language: We included systematic reviews and meta-analyses published in English. Non-English records were excluded due to resource constraints.

A systematic search was conducted in PubMed, Web of Science, and Scopus from database inception to August 30, 2025. Search terms combined Medical Subject Headings (MeSH) and free-text keywords relating to children, obesity, TCM, and evidence synthesis (Tables S1-S3). Reference lists of included reviews were also screened to identify additional eligible studies.

All search results were exported into EndNote for de-duplication and then screened independently by two reviewers (Author A and Author B). Titles and abstracts were first screened for relevance, followed by full-text review of potentially eligible articles. Disagreements were resolved through discussion or consultation with a third reviewer (Author C). The study selection process is summarized in Figure 1 (PRISMA 2020 flowchart).

Two reviewers independently extracted data using a pre-piloted form. Extracted variables included: first author and year of publication, country of included trials, number of studies and participants, age range of populations, interventions and comparators, outcomes assessed, quality assessment tool used, and main findings of each review.

The methodological quality of included reviews was appraised independently by two reviewers using the AMSTAR-2 (A MeaSurement Tool to Assess Systematic Reviews, Version 2) instrument. This 16-item tool emphasizes seven critical domains (protocol registration, adequacy of search, justification for excluded studies, risk of bias assessment, appropriateness of meta-analytic methods, consideration of risk of bias in interpretation, and publication bias assessment). Reviews were categorized as high, moderate, low, or critically low confidence based on AMSTAR-2 guidance.

Given the heterogeneity of interventions, populations, and reported outcomes, a qualitative synthesis was undertaken. Findings were narratively summarized according to intervention categories, including herbal medicine, acupuncture and moxibustion, acupressure/massage/cupping, and dietary therapy or exercise.

To evaluate redundancy across reviews, an overlap analysis was performed by mapping primary studies to each systematic review. The extent of overlap was quantified using the Corrected Covered Area (CCA) method, which provides a standardized measure of overlap between evidence syntheses.

All analyses and visualizations were conducted in R (version 4.3.2; R Foundation for Statistical Computing, Vienna, Austria) using RStudio (version 2024.04.2). Data extraction sheets were imported and cleaned with the readxl and tidyverse packages to ensure consistency in bibliographic and methodological variables. Methodological quality assessments (AMSTAR-2) were summarized graphically using ggplot2, with bubble plots generated for item-level ratings and proportional stacked bar charts for overall confidence ratings. Evidence overlap across reviews was visualized with heatmaps created in ggplot2, and the study selection process was depicted using a PRISMA 2020 flow diagram constructed with the DiagrammeR and prisma R packages.

The initial database search across multiple sources (PubMed, Web of Science, and Scopus) identified a total of 15 records. After the removal of duplicates, 12 unique records remained for title and abstract screening. Of these, two were excluded as irrelevant, leaving 10 full-text articles assessed for eligibility.

Following detailed full-text review, one study were excluded for insufficient outcome data. Ultimately, three systematic reviews and meta-analyses met the inclusion criteria for this umbrella review: Quan et al. (12), Cui (13), and Lee and Kwon (6). The detailed process of study identification, screening, eligibility assessment, and final inclusion is illustrated in Figure 1, following the PRISMA 2020 flowchart.

A total of three systematic reviews were included, all of which focused on Traditional Chinese Medicine (TCM) interventions for childhood obesity. The main characteristics of these reviews are presented in Table 1.

Cui (13) conducted a meta-analysis of 20 clinical studies from China evaluating acupuncture and moxibustion for simple childhood obesity. Compared with control interventions, acupuncture and moxibustion significantly reduced BMI, waist circumference, fasting blood glucose, triglycerides, and low-density lipoprotein cholesterol, while increasing high-density lipoprotein cholesterol. However, changes in leptin levels were not significant. Study quality was rated moderate overall, with heterogeneity observed across trials.

Lee and Kwon (6) conducted a large network meta-analysis (33 RCTs, predominantly from China) comparing multiple East Asian traditional medicine modalities. Their analysis indicated that cupping combined with acupressure had the greatest beneficial effect on BMI and weight reduction in children with simple obesity, followed by chuna and herbal medicine. Adverse events were rare and mild. The certainty of evidence was generally low to moderate due to methodological limitations in the primary studies.

Finally, Quan et al. (12) synthesized evidence from 15 randomized controlled trials (RCTs) conducted in China and South Korea, with a total of 1,288 participants aged 6–17 years. Their findings suggested that acupuncture—particularly body acupuncture combined with diet and exercise—was associated with significant improvements in body mass index (BMI), body weight, and lipid metabolism, although methodological limitations such as lack of blinding reduced confidence in the results.

Across the included reviews, most pooled estimates demonstrated statistically significant reductions in BMI, body weight, waist circumference, and metabolic markers with TCM interventions. However, certain outcomes such as leptin changes were not consistently significant. Taken together, these reviews consistently support the potential of TCM-based interventions—particularly acupuncture, moxibustion, herbal medicine, and combined non-pharmacological therapies—as beneficial strategies for managing childhood obesity. Nonetheless, the methodological quality of available evidence remains suboptimal, underscoring the need for rigorously designed, large-scale trials.

The methodological quality of the included reviews was appraised using the AMSTAR-2 instrument, and the findings are summarized in Figure 2. Overall, the quality of evidence synthesis was variable, with ratings ranging from low to moderate confidence.

Quan et al. (12) and Cui (13) were rated as low quality due to one critical flaw each—neither review provided a list of excluded studies with reasons (Item 7). Both reviews otherwise adhered to core methodological standards, including protocol registration, comprehensive database searches, duplicate selection and extraction, and use of appropriate tools for risk-of-bias assessment. However, they did not report funding sources of the primary trials and only partially addressed the impact of risk of bias in their interpretations, which contributed to the lower overall rating.

Lee and Kwon (6) achieved a moderate quality rating, as it satisfied all seven critical AMSTAR-2 domains. This review was distinguished by its comprehensive search across 12 databases, preregistration on PROSPERO, and provision of a supplementary list of excluded studies with reasons. The authors also incorporated risk of bias into their synthesis using Cochrane RoB and GRADE. Only minor non-critical weaknesses were identified, such as limited discussion of the influence of study heterogeneity on conclusions.

Across reviews, critical domains most frequently unmet were reporting of excluded studies (Item 7) and consideration of risk of bias when interpreting results (Item 13). In contrast, domains related to search strategy (Item 4), protocol registration (Item 2), and risk-of-bias assessment of included studies (Item 9) were generally well-addressed.

Taken together, these findings indicate that while TCM reviews on childhood obesity demonstrate generally sound methodological practices, improvements are needed in transparency and in integrating risk of bias into evidence interpretation. This variability in methodological quality underscores the importance of cautious interpretation of pooled findings.

An overlap analysis was performed to identify whether the same primary studies were included across the three systematic reviews and meta-analyses. In total, 68 unique primary trials were identified [20 from Cui (13); 33 from Lee and Kwon (6); and 15 from Quan et al. (12)]. Several studies appeared in more than one review, indicating substantial redundancy in the evidence base (Figure 3).

This overlap demonstrates that although each review had a distinct focus—Lee and Kwon (6) synthesized a broad range of East Asian traditional medicine modalities, Cui (13) concentrated on acupuncture and moxibustion, and Quan et al. (12) focused exclusively on acupuncture—there is considerable reliance on a shared pool of Chinese and Korean RCTs. Such overlap inflates the apparent evidence base and increases the risk of double-counting data in any higher-level synthesis. Corrected Covered Area (CCA) analysis confirmed a moderate-to-high degree of overlap, suggesting that the existing systematic reviews do not represent entirely independent bodies of evidence.

This finding highlights the importance of mapping overlap in evidence syntheses, as it provides context for interpreting conclusions and emphasizes the need for more original, high-quality trials rather than additional reviews recycling the same primary data.

This umbrella review adhered to PRISMA 2020, was preregistered, and applied AMSTAR-2 with duplicate, independent assessment and consensus, reporting item-level ratings transparently (Figure 2). Several limitations must be acknowledged. First, only three SRs/MAs met eligibility and methodological quality was variable—two were rated low by AMSTAR-2 (Figure 2). Second, the overlap analysis showed moderate-to-high redundancy across reviews, with many primary RCTs shared across Chinese and Korean settings; this reduces the independence of findings and risks double-counting (Figure 3). Third, most underlying trials were small, often lacked allocation concealment and blinding, and were conducted in single-country settings, limiting generalizability. Fourth, the evidence synthesized in all included SRs came from China (with one review also including Korea), so multicenter international RCTs in diverse pediatric populations are needed. Fifth, our searches covered PubMed, Web of Science, and Scopus; not searching Cochrane Library, Embase, and major Chinese databases could have missed additional SRs/MAs. Sixth, restricting inclusion to English-language reviews may introduce language bias in a field with substantial Chinese-language scholarship. Seventh, although AMSTAR-2 provides a structured framework, some judgments are inherently subjective; we mitigated this through duplicate assessment and prespecified criteria. Finally, the short follow-up in most trials precludes confident conclusions about sustained efficacy. Collectively, these limitations underscore the need for prospectively registered, high-quality systematic reviews with broader database coverage and for adequately powered, multicenter RCTs with longer follow-up.