Acupuncture and Obesity
By Yoon Hang "John" Kim, MD, MPH, DABMA, and Michael Kao. Dr. Kim is Director, Summit Center for Health and Healing, Newnan, GA. Mr. Kao is a student at the University of California, Berkeley, and the Acupuncture and Integrative Medicine College, Berkeley, CA. Dr. Kim and Mr. Kao report no consultant, stockholder, speaker's bureau, research, or other financial relationships with companies having ties to this field of study.
During the past 20 years, obesity among adults has risen significantly in the United States. The latest data from the National Center for Health Statistics show that 30% of U.S. adults 20 years of age and older—more than 60 million people—are obese.1 This increase is not limited to adults. The percentage of young people who are overweight has more than tripled since 1980. Among children and teens aged 6-19 years, 16% (more than 9 million young people) are considered overweight.2 Although one of the national health objectives for the year 2010 is to reduce the prevalence of obesity among adults to less than 15%, current data indicate that the situation is worsening rather than improving.
The increasing rates of obesity raise concern because of their implications for Americans' health. Being overweight or obese increases the risk of many diseases and health conditions, including:
- Type 2 diabetes
- Coronary heart disease
- Gallbladder disease
- Sleep apnea and respiratory problems
- Some cancers (endometrial, breast, and colon)3
Current conventional medical approaches include behavioral modification strategies involving nutrition and physical activity, medications, and gastric bypass surgery. Gastric bypass procedures in the United States have increased rapidly since 1998. Of note, gastric bypass patients were primarily women (84%), with a 10% complication rate.4 Despite the medical advances, the prevalence of overweight and obesity continues to increase at an alarming rate.5
Interest in complementary and alternative medicine (CAM) therapies for reducing body weight is increasing given the higher prevalence of obesity and the lack of effective methods to address the problem within the conventional medical approach. Pittler and Ernst published a systematic review evaluating the evidence of complementary therapies for treating obesity.6 The modalities evaluated included acupuncture, acupressure, dietary supplements, homeopathy, and hypnotherapy. They concluded that two modalities, hypnotherapy and ephedrine-containing dietary supplements, may lead to small reduction of body weight.6 However, the potential adverse effects of ephedrine include increased risk of psychiatric, autonomic, or gastrointestinal symptoms and heart palpitations.7 FDA has taken several regulatory actions with regards to supplements containing ephedrine.8
This article will present and evaluate the evidence for the use of acupuncture for weight loss.
Mechanism of Action
Acupuncture is one of the most thoroughly researched CAM modalities.9 It is widely believed that acupuncture initiates stimulation of small diameter nerves in muscles, sending impulses to the spinal cord, midbrain, and pituitary, and results in the release of neurotransmitters such as monoamines and endorphins.9 The discovery of naloxone, an endorphin antagonist, helped to investigate and to document the role of endorphins and acupuncture. In addition to endorphin, the levels of monoamines such as serotonin and norepinephrine have been shown to increase during acupuncture treatments.10 Microinjection of monoamine antagonists has been shown to block the effects of acupuncture.11,12 Furthermore, Sprott et al demonstrated the rise of serum serotonin during acupuncture treatments.13 The neurotransmitter activation by acupuncture treatment provides a possible mechanism behind the treatment of obesity utilizing acupuncture.
Studies document that the stimulation of the auricular acupuncture points affects the satiety center and lead to improved weight loss in both obese and non-obese rats.14 There also have been reports of reduced appetite and cravings from patients wearing auricular acupuncture devices, such as press needles, staples, or beads.15
Since the 1970s, an increasing number of case series and uncontrolled studies have demonstrated encouraging results for acupuncture for the treatment of obesity. Most clinical trials testing the efficacy of acupuncture for treating obesity have been descriptive in nature.16 Many reports from China appear to be positive with regard to the use of acupuncture for weight loss.16
In a systematic review evaluating the effectiveness of acupuncture and acupressure for weight reduction, Ernst identified four studies based on placebo/sham-controlled clinical trials and concluded that no clear evidence existed to show that acupuncture/acupressure was effective in reducing appetite or body weight.17
Lacey et al published a review article on utilization of acupuncture for the treatment of obesity and described limitations of the studies.16 The critique of the studies included the lack of control in study design, the short treatment duration (≤ 12 weeks), and the utilization of nonstandard treatment protocols. They concluded that further studies should explore of the role of acupuncture as a complementary modality in weight management rather than using acupuncture as the sole modality to treat obesity.16 This conclusion is consistent with the limitation of acupuncture as the only modality to treat complex problems such as addiction.18
Clinical Trials with Multiple Arms
Stein et al conducted an eight-week randomized, controlled trial (n = 78) with four treatment arms: acupuncture (auricular and body acupuncture), sham acupuncture, behavioral modification, and wait-list controls.19 The acupuncture group lost 6.0 lbs and the behavior modification group lost 9.3 lbs. The sham acupuncture group lost 2.7 lbs while the wait-list control groups demonstrated a weight gain of 1.1 lb. The weight of the real acupuncture and behavior modification groups differed significantly from the wait-listed controls (P < 0.05). The result demonstrates stronger treatment effects of acupuncture and weaker treatment effects of sham acupuncture. This result is consistent with other studies, illustrating the need for sham acupuncture to serve as a control for the non-specific effect of needling.18
In a randomized controlled trial, Sun and Xu compared a standardized treatment of auricular acupressure and body acupuncture over 90 days in 110 subjects to 51 controls who took herbal supplements.20 The results demonstrated that the acupuncture treatment group showed significantly greater reduction in weight than the control group (P < 0.01). Although a comparison group was utilized, there was no sham acupuncture group, which leaves open the possibility of a non-specific needling effect of acupuncture being responsible for the treatment effect. The effect of acupuncture could have been a result of inserting needles rather than the proposed protocol utilized in the trial.
Cabioglu and Ergene conducted a randomized controlled trial with 55 patients comparing three groups: auricular and body acupuncture, diet restriction, and control.21 A 4.8% weight reduction was observed in the acupuncture group whereas a 2.9% weight reduction was observed in the diet restriction group after three weeks of therapy. The weight reduction in the acupuncture group was more significant than that reported in both the diet and the control groups (P < 0.05). Furthermore, subjects in the diet group lost more weight than those in the control group (P < 0.05).
Hsu et al randomized 72 patients into one of three groups: electroacupuncture, sit-up exercises, and no intervention.22 Result showed significantly greater reductions in body weight in the electroacupuncture group compared to both the exercise (P = 0.009) and no intervention (P = 0.004) groups.
Clinical Trials with Sham Acupuncture
Mazzoni et al conducted a randomized controlled trial of 40 patients comparing body acupuncture and sham acupuncture.23 The results showed no differences in weight change between groups. A design weakness of this study is the lack of auricular acupuncture in the protocol; all other studies employed auricular acupuncture. This study suggests that body acupuncture without auricular acupuncture does not result in weight loss. Another possibility is the treatment effect of acupuncture may not be strong enough to cause weight loss as a sole modality.
Shiraishi et al conducted a randomized controlled study with 60 patients comparing auricular acupuncture vs. sham acupuncture.24 While 63% of the acupuncture group lost weight, none in the sham acupuncture group lost weight.
Clinical Trials with Acupuncture as Adjunctive Treatment to Diet
Shafshak demonstrated that auricular electroacupuncture combined with a 1,000 kcal/d diet resulted in greater weight loss (P < 0.05) compared to those treated with sham acupuncture.25 Similar results were obtained by Bahadori et al where individuals in the diet and acupuncture group lost more than twice as much weight as the diet-only controls (P < 0.005).26 Kuruvilla conducted a randomized controlled trial with 20 patients comparing auricular acupuncture plus diet and physical activity vs. diet and physical activity.27 Mean weight loss for patients in the acupuncture group was 9 lbs, while those in the control group lost 4 lbs (P = 0.03). This trial illustrates the potential role of acupuncture as an adjunctive therapy in an integrated weight-loss program that includes lifestyle change.
Khoo conducted a randomized controlled trial with 30 patients comparing auricular acupuncture plus diet and physical activity vs. diet and physical activity.28 Subjects in the acupuncture group lost an average of 10.6 lbs whereas the control group showed 5.3 lb weight loss. It appears that the addition of acupuncture to lifestyle modification results in about twice the amount of weight loss than with lifestyle modification alone.
Clinical Trials with Device Stimulating Acupuncture Points
Two trials have tested the effectiveness of devices stimulating auricular acupuncture points. Allison et al conducted a randomized controlled trial of 96 patients in which the treatment group received auricular stimulation through acupressure device (Acu-Stop 2000) and the control group received wrist stimulation.29 There was no difference in both groups for weight loss.
Richards and Marley performed a randomized control trial in 60 patients comparing electric stimulation of auricular acupuncture points (AcuSlim) to sham stimulation of thumbs.30 Both the number of subjects who lost weight and the mean weight loss were significantly higher in the treatment group (P < 0.05) than the sham group.
In 2003, Wozniak et al randomized 74 patients to laser stimulation of body and auricular acupuncture points and diet or diet alone.31 The intervention group receiving both laser stimulation of acupuncture points and diet achieved significantly greater weight loss than the control group (P < 0.01). This study illustrates a possibility of utilizing laser as another method to stimulate acupuncture points.
Adverse Effects/Safety Trials
The safety of acupuncture is well documented. Ernst and White conducted a systematic review to determine the incidence of adverse events associated with acupuncture.32 The most common adverse events were needle pain, tiredness, and bleeding. Feelings of faintness and syncope were uncommon. Pneumothorax was rare, occurring only twice in nearly 250,000 treatments. However, the use of non-sterile needles may cause infections. One overview identified 126 documented cases of hepatitis associated with acupuncture.33 Of note, there has been a case report of auricular chondritis secondary to acupuncture.34 This potential risk increases with auricular acupuncture styles that leave needles in place for extended amounts of time.
A significant amount of preliminary data exists supporting the use of acupuncture as a complementary modality to lifestyle modification in the treatment of obesity. Because results from preliminary trials have not been confirmed in large, multicenter studies, more research is needed.
Obesity is a prevalent medical problem with huge social, economic, and medical implications. Given the growing seriousness of the problem and lack of efficacious conventional medical approaches, physicians may choose to employ a trial of acupuncture in addition to therapeutic lifestyle change for the treatment of obesity.
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