Effects of Auricular Acupuncture on Anthropometric,Lipid Profile,Inflammatory,and Immunologic Markers: A Randomized Controlled Trial Study

Abstract

Objectives:

A randomized controlled clinical trial was performed to examine the effectiveness of auricular acupuncture on body weight loss and its impact on lipid profile, and immunologic and inflammatory markers in obese subjects.

Methods:

Participants (n=204) were randomized to therapeutic acupuncture and control groups. Subjects received authentic (cases) or sham (controls) acupuncture for 6 weeks (first period) in combination with a low-calorie diet. In the next 6 weeks (second period), the low-calorie diet was used on its own. Subjects were assessed at the beginning and 6 and 12 weeks later. In addition to anthropometric and lipid parameters, serum anti-heat shock protein (Hsp)-27, 60, 65, 70 and high sensitive C-reactive protein (hs-CRP) levels were assessed.

Results:

In the first period, anthropometric parameters and hs-CRP changed significantly in both groups, while significant changes in anti-Hsp antibodies were only observed in case subjects. In the second period, which shows the sustainable effects of acupuncture, changes in anthropometric parameters were more prominent in controls, while significant reductions in the group receiving authentic acupuncture were maintained for anti-Hsp antibodies. A comparison between the first and second period in both groups showed that the changes for most of the parameters were more significant in the first period. Comparison between cases and controls showed that authentic acupuncture was more effective in reducing the levels of anthropometric factors and anti-Hsp antibodies but not hs-CRP.

Conclusions:

Auricular acupuncture in combination with diet restriction was effective for weight loss and dyslipidemia. Moreover, it was found that it has immunomodulatory but not anti-inflammatory effects on the immune system by regulation of the levels of anti-Hsp antibodies.

Introduction

T here has been a substantial increase in the global prevalence of obesity and as a consequence, several other disorders such as hypertension, diabetes, dyslipidemia, and cardiovascular disease¹ are also increasing in their prevalence. The general principles in treatment of obesity are to achieve weight loss, to maintain this reduction in body weight following this loss, and finally to reduce the risk factors for obesity. It would be desirable to control obesity by safe and effective treatment interventions, and among the different methods, acupuncture is one of the most popular complementary treatments.

In Traditional Chinese Medicine, life force known as Qi is thought to circulate within energy pathways or “meridians” longitudinally throughout the body. Theoretically, acupuncture can balance an excess/deficiency of Qi by the specific manner of point stimulation during illness. Different sets of acupuncture points (acupoints) are used depending on which organ needs to be inhibited or energized,² resulting in release of some neurochemicals such as endorphin, monoamines, cortisol, and anti-inflammatory substances.^3
–5 Among several methods to stimulate acupoints,⁶ needling is one of the most common methods. The needle can be kept for varying lengths of time and can be stimulated manually or electrically (electroacupuncture). “Hunger” and “Stomach” points (for satiety and fullness) and “Shenmen” (for sedation and analgesia) are the most common acupoints used during auricular acupuncture (reviewed by Cabyoglu et al.⁷). Also, “Sanjiao”⁸ and “Center of Ear” are other used acupoints in this study that were used for general hemostatic balance and enhancing intestinal motility. Positive results have been reported about the significant weight loss achieved with acupuncture therapy.^9

–12

Heat shock proteins (Hsp) are highly conserved proteins expressed by several cell types following exposure to environmental stresses. Over the past 2 decades, there has been an increasing interest in the relationship between Hsp and cardiovascular disease, and particularly whether an autoimmune response may be implicated by formation of anti-Hsp antibodies.¹³ In this regard, most of these studies have focused on the relation between cardiovascular disease and Hsp/anti-Hsp-60, −65, −70, while there are recent data that support the role of Hsp/anti-Hsp27 in cardiovascular events.¹³ There is a hypothesis¹⁴ that has been supported by different studies showing that autoimmunity to Hsps (formation of anti-Hsp antibodies) may contribute in progression of atherosclerosis (reviewed by Ghayour-Mobarhan et al.).¹³

Increased serum C-reactive protein (CRP) is a feature of systemic inflammation.¹⁵ Furthermore, CRP has been positively related to various inflammatory diseases including obesity.¹⁶ Moreover, there are large cross-sectional studies showing that CRP is positively associated with measures of adiposity such as body–mass index (BMI) and waist circumferences (WC).^17,18 Obesity is associated with higher levels of CRP,¹⁶ and following weight reduction there is a decrease in serum CRP levels.^19,20

There are several studies that have evaluated the effect of acupuncture in management of obesity. However, most studies have methodologic limitations, including small sample sizes and inadequately controlled study design.^2,12 In addition, safe interventions that are able to reduce the plasma levels of hs-CRP and anti-Hsp antibodies would be desirable. To the authors' knowledge, the effect of acupuncture on body weight loss has not been evaluated in parallel with its effects on inflammatory and immunological markers such as hs-CRP and anti-HSP antibodies. Thus, the aim of this study was to perform a randomized clinical trial in patients suffering from obesity to examine the effectiveness of auricular acupuncture on body weight loss, lipid profile, and serum inflammatory and immunological markers.

Methods and Subjects

Study design and subjects

Two hundred and twenty (220) overweight and obese subjects were recruited from the nutrition clinic, Quem Hospital, Mashhad, Iran. In this study, overweight was defined as a BMI of 25 to <30, and a BMI of ≥30 was defined as obesity. Subjects had neither received any other weight control measures nor had any medical and/or drug history within the last 3 months before their participation in the study. Participants were informed about the study by both verbal explanation and written information sheets. Volunteers were given time to discuss the study and were encouraged to ask questions. Those who had exclusion criteria such as diabetes, severe hypertension, heart disease, endocrine abnormalities, pregnancy, and who refused to participate in any points were withdrawn from the study. Finally, 204 subjects were enrolled in the study and were randomized to 2 groups of case and control of auricular acupuncture (each group had 102 subjects). The subjects were aged between 18 and 55 years with BMI between 25 and 45 kg/m². Each patient gave written informed consent to participate in the study, which was approved by the Mashhad University of Medical Science Ethics Committee.

Anthropometric and biochemical assessments were measured pre- and post-treatment. The participants were asked to follow an isocaloric diet (washout diet) for 2 weeks before starting the trial to match the two groups for initial diet, and a low-calorie diet for 6 weeks. The low-calorie diet consisted of 1000-kcal deficit per day, less than the individual daily energy expenditure. The resting energy expenditure was calculated using the equation of Harris Benedict²¹ and was used to determine the amount of food per day for each participant. The washout diet and the 6-week dietary program for each participant were planned by a nutritionist and were based on the participant's energy expenditure. The diet was prescribed and the participant's compliance was checked every week.

Acupuncture treatment

The standardized acupuncture points were selected according to the theory of Chinese medicine and clinical experience by several consultants and Chinese-medicine doctors of this study. Six (6) auricular acupuncture points on the ear, including Shen Men (TF4), Stomach (CO4), Hunger point, Mouth (CO1), Center of Ear (HX1), Sanjiao (CO17) in the case group that applies routine ear-pressing plaster with seed²² (Fig. 2). After sterilizing the acupoints with 75% alcohol preparation pads, the acupuncturist inserted the ear-pressing plaster with seed into the acupoints. Ear-pressing plasters were applied to acupoints on one ear in each treatment and were kept on the ear for 3 days.²² All subjects were requested to apply pressure to the auricular points 30 minutes before eating for about 20 seconds. They received two treatments per week for a total of 6 weeks, which means that seed plasters were changed once each 3–4 days. Acupuncture was performed on selected ear points on one ear in the first session and the opposite ear in the next session and so on.

FIG. 2.

Real and sham acupoints which were used in the present study.

In the sham (control) group of auricular acupuncture, subjects were given sham auricular acupuncture using placebo needles (ear-pressing plaster without seed). Hip (AH5), spleen (CO13), nose and esophagus (CO2) were used in control group (Fig. 2). The treatment procedure was the same as that of the case group. In sham points, those that were used were not associated with obesity, but the plasters on the ears were without seed and had no electrical stimulation on the acupoints.

Blood sampling, routine biochemical analysis, and serum anti-Hsp antibody titer measurements

Blood samples were taken from each patient for analysis after 12-hour fasting 3 times during the study (at the beginning, and 6 and 12 weeks later). A full fasted lipid profile comprising total cholesterol, triglycerides, high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein-cholesterol (LDL-C) was determined for each subject. Serum lipid and fasting blood sugar concentrations were measured enzymatically with the use of commercial kits. hs-CRP was measured by a polyethylene glycol (PEG)-enhanced immunoturbidimetry method with an Alycon analyzer (Abbott, Chicago, IL). Serum Hsp27, 60, 65, and 70 antibody titers were measured using in-house enzyme-linked immunoassays, as has previously been described.^23,24

Statistical analysis

SPSS software (version 16, Chicago, IL) was used to perform the statistical analysis. Data were checked for normality using the SPSS test. Values were expressed as mean±standard error of the mean or, in the case of non-normally distributed data, as median and interquartile range. Data that were normally distributed were analyzed using Student's t-test. Data found to be non-normally distributed were analyzed using the nonparametric Mann–Whitney test. For comparison between two related samples, the paired t-test (normally distributed data) and the Wilcoxon signed-ranks test (non-normally distributed data) were used. For multiple comparisons of parameters, Bonferroni corrections were made. A two-sided p-value of <0.05 was considered statistically significant.

Results

Demographic data

At the end of the study, 35 subjects withdrew for personal reasons and 169 participants completed the study (Fig. 1). The analysis showed that sex, age, basal levels of anthropometric parameters, lipid profiles, levels of anti-Hsp antibodies and hs-CRP were not significantly different between case and control groups (p>0.05). Clinical and biochemical characteristics of participants are summarized in Table 1.

FIG. 1.

Trial profile and design.

Table 1.

Comparison of Clinical and Biochemical Characteristics of Participants

Variable	Case (n=86)	Control (n=83)
Age (year)	37.29±1.00	38.73±1.10
Weight (kg)	84.33±1.64	81.53±1.81
Height (cm)	161.10±0.79	158.94±0.80
Body fat (%)	37.39±0.64	36.84±0.57
BMI (kg/m²)	32.15±0.47	31.40±0.41
WC (cm)	102.75±1.33	101.26±1.12
HC (cm)	115.13±0.92	112.65±0.90
WC/HC ratio	0.89±0.007	0.89±0.006
FBG (mg/dL)	83.63±1.82	90.08±2.89
TC (mg/dL)	151.31±3.16	159.79±4.23
TG (mg/dL)	109.16±4.51	118.27±7.006
HDL-C (mg/dL)	37.61±0.87	38.55±0.87
LDL-C (mg/dL)	92.31±2.73	97.58±3.11
DBP (mmHg)	73.62±1.02	75.87±0.09
SBP (mmHg)	105.73±1.44	107.32±0.174
Anti-HSP27 antibody	0.36 (0.34–0.39)	0.35 (0.33–0.38)
Anti-HSP60 antibody	0.74 (0.70–0.76)	0.74 (0.72–0.76)
Anti-HSP65 antibody	0.79 (0.78–0.82)	0.79 (0.78–0.82)
Anti-HSP70 antibody	0.60 (0.57–0.63)	0.60 (0.59–0.64)
hs-CRP	1.97 (1.30–4.05)	2.25 (1.30–4.07)

BMI, body mass index; WC, waist circumference; HC, hip circumference; FBG, fasting blood glucose; TC, total cholesterol; TG, triglycerides; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol, DBP, diastolic blood pressure; SBP, systolic blood pressure; Anti-HSP antibody, anti-heat shock protein; hs-CRP, high-sensitivity C-reactive protein. Values are expressed as mean±standard error of the mean, or median and interquartile range. Independent sample t-test (for normally distributed data) and Mann–Whitney test (for non-normally distributed data) were used for comparison of 2 groups.

Comparison at first 6 weeks (first period)

In the acupuncture auricular group, in the first period of intervention, which comprised acupuncture and a low-calorie diet, significant changes in body weight (p<0.001), body fat percentage (p<0.01), BMI (p<0.01), WC (p<0.001), hip circumference (HC) (p<0.001) and HDL-C (p<0.001) was observed. In the sham auricular acupuncture group, after 6 weeks of intervention, body weight (p<0.001), BMI (p<0.001), WC (p<0.01), and HDL-C (p<0.001) changed significantly. Interestingly, in the first period of study, all immunological and inflammatory factors including anti-Hsp antibodies and hs-CRP decreased significantly in cases (p<0.001), however, only anti-Hsp70 antibodies (p<0.05) and hs-CRP (p<0.001) were reduced statistically in the control group. Table 2 summarizes the levels of different parameters.

Table 2.

Comparison of Clinical and Biochemical Characteristics of Participants of Auricular Group

	Authentic group			Sham group
Variable	1st sample	2nd sample	3rd sample	1st sample	2nd sample	3rd sample
Weight (kg)	84.33±1.64	81.35±1.87 α	81.24±2.07α	81.53±1.81	77.98±1.48α	77.87±1.76α
Body fat (%)	37.39±0.64	36.60±0.82 α	36.53±0.90α,β	36.84±0.57	37.18±0.75	36.62±0.83α,β
BMI (kg/m²)	32.15±0.47	30.85±0.51 α	30.90±0.61α	31.40±0.41	31.04±0.55α	30.70±0.61α,β
WC (cm)	102.75±1.33	98.04±1.34α	99.95±1.64α	101.26±1.12	98.17±1.48α	103.50±1.4β
HC (cm)	115.13±0.92	110.87±1.11 α	111.56±1.31 α	112.65±0.90	112.14±1.19	113.70±1.23β
WC/HC ratio	0.89±0.007	0.88±0.01	0.89±0.009	0.89±0.006	0.87±0.009	0.91±0.007β
FBG (mg/dL)	83.63±1.82	80.70±1.43	87.10±2.07β	90.08±2.89	80.00±1.59	87.52±1.65β
TC (mg/dL)	151.31±3.16	155.58±4.50	168.75±3.66α	159.79±4.23	157.67±4.56	179.28±5.04α
TG (mg/dL)	109.16±4.51	99.90±5.23	105.52±6.52	118.27±7.006	102.57±7.73	105.36±6.86
HDL-C (mg/dL)	37.61±0.87	39.34±1.59α	58.11±5.81α,β	38.55±0.87	40.92±1.37α	52.78±3.38α,β
LDL-C (mg/dL)	92.31±2.73	97.14±3.59	89.53±6.79	97.58±3.11	97.13±3.49	105.42±5.66
Anti-HSP27	0.36 (0.34–0.39)	0.34 (0.32–0.37) α	0.33 (0.31–0.36) α,β	0.35 (0.33–0.38)	0.35 (0.33–0.39)	0.35 (0.32–0.38) α
Anti-HSP60	0.74 (0.70–0.76)	0.72 (0.68–0.75) α	0.71 (0.66–0.74) α,β	0.74 (0.72–0.76)	0.74 (0.71–0.75) α	0.74 (0.70–0.76)
Anti-HSP65	0.79 (0.78–0.82)	0.78 (0.76–0.80) α	0.77 (0.75–0.78) α,β	0.79 (0.78–0.82)	0.79 (0.77–0.82) α	0.79 (0.76–0.81) α
Anti-HSP70	0.60 (0.57–0.63)	0.59 (0.55–0.62) α	0.56 (0.54–0.60) α,β	0.60 (0.59–0.64)	0.60 (0.58–0.63) α	0.60 (0.57–0.63) α
hs-CRP	1.97 (1.30–4.05)	0.0 (0.0–1.27) α	1.36 (0.04–3.19) β	2.25 (1.30–4.07)	0.30 (0.0–2.47) α	2.02 (0.57–4.92) β

BMI, body mass index; WC, waist circumference; HC, hip circumference; FBG, fasting blood glucose; TC, total cholesterol; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol, HSP, heat shock protein; CRP, C-reactive protein. Values are expressed as mean±standard error of the mean, or median and interquartile range. α means significant changes in comparison with first sample and β means significant changes in comparison with second sample.

Comparison at second 6 weeks (second period)

In the acupuncture auricular group, in the second period of intervention with low-calorie diet alone, significant changes were found in body fat percentage (p<0.05) and HDL-C (p<0.001). In the control group, significant changes were observed for body fat percentage (p<0.05), BMI (p<0.01), WC (p<0.001), HC (p<0.01), WC/HC (p<0.01), and HDL-C (p<0.001). The same as the first period of the study, all immunological and inflammatory factors including anti-Hsp antibodies and hs-CRP levels maintained their reduction significantly in the authentic acupuncture group (p<0.001), while in controls no statistically significant changes were seen for these parameters except for hs-CRP (p<0.001) (Table 2).

Comparison for the whole period of the study

After 12 weeks of study, in the acupuncture auricular group, significant changes were found in body weight (p<0.001), body fat percentage (p<0.001), BMI (p<0.001), WC (p<0.01), HC (p<0.001), total cholesterol (p<0.001), and HDL-C (p<0.001) (Table 2). In the control group, body weight (p<0.001), body fat percentage (p<0.05), BMI (p<0.001), total cholesterol (p<0.001) and HDL-C (p<0.01) changed significantly. Overall, immunological but not inflammatory factors including anti-Hsp27 antibodies levels decreased significantly (p<0.001) in the authentic but not the control group (Table 2).

Comparison between changes in the first and second period of study

In the acupuncture body group, changes in the first (acupuncture and low-calorie diet) versus second (only low-calorie diet) period was significantly different for body weight (p<0.001), BMI (p<0.001), WC (p<0.001), HC (p<0.001), total cholesterol (p<0.05), HDL-C (p<0.005), anti-Hsp-27 (p<0.01) and −60 antibodies (p<0.05) and hs-CRP (p<0.001). In all the aforementioned parameters except HDL-C, the changes were more significant in the first period when compared with the second one. In the acupuncture control group, body weight (p<0.01), WC (p<0.001), HC (p<0.01), WC/HC ratio (p<0.01), HDL-C (p<0.05), anti-Hsp60 (p<0.01) and hs-CRP (p<0.01) were significantly different. All of the aforementioned changes were more significant for the first period of study compared with second period except the HDL-C (Table 3).

Table 3.

Comparison of Changes in Clinical and Biochemical Characteristics of Auricular Acupuncture

Real group					Sham group
Variable	1st period	2nd period	Whole period	p-Value 1 vs. 2	1st period	2nd period	Whole period	p-Value 1 vs. 2	p-Value R. vs. S.
Weight (kg)	3.38±0.25	0.22±0.14	3.66±0.32	0.000	1.99±0.25	0.18±0.19	2.27±0.33	0.000	1st p.: 0.000 2nd p.: 0.865 Wh p.: 0.004
Body fat (%)	0.86±0.27	0.44±0.17	1.82±0.37	0.096	0.30±0.36	0.76±0.29	0.77±0.30	0.276	1st p.: 0.212 2nd p.: 0.322 Wh p.: 0.040
BMI (kg/m²)	1.38±0.16	0.18±0.11	1.66±0.19	0.000	0.63±0.15	0.29±0.098	0.95±0.17	0.107	1st p.: 0.002 2nd p.: 0.474 Wh p.: 0.010
WC (cm)	5.17±0.92	−0.72±0.44	3.83±1.08	0.000	3.08±0.99	−4.44±1.01	−1.54±1.1	0.000	1st p.: 0.131 2nd p.: 0.000 Wh p.: 0.001
HC (cm)	4.16±0.52	0.05±0.48	4.17±0.67	0.000	1.47±0.57	−1.62±0.54	−0.11±0.60	0.002	1st p.: 0.001 2nd p.: 0.022 Wh p.: 0.000
WC/HC ratio	0.012±0.008	−0.005±0.003	0.0008±0.08	0.291	0.016±0.008	−0.027±0.008	−0.01±0.009	0.004	1st p.: 0.743 2nd p.: 0.016 Wh p.: 0.397
FBG (mg/dL)	−1.68±1.97	−6.02±1.99	−5.93±2.55	0.105	3.59±1.97	−5.69±1.69	−2.32±1.80	0.018	1st p.: 0.069 2nd p.: 0.904 Wh p.: 0.287
TC (mg/dL)	−4.59±3.66	−18.13±3.39	−21.18±4.19	0.032	−0.46±4.59	−13.76±4.99	−16.37±4.23	0.142	1st p.: 0.484 2nd p.: 0.455 Wh p.: 0.435
TG (mg/dL)	6.98±4.23	−1.15±5.04	6.77±5.03	0.261	12.71±6.78	0.94±7.71	15.30±6.60	0.281	1st p.: 0.292 2nd p.: 0.848 Wh p.: 0.329
HDL-C (mg/dL)	−2.19±1.49	−23.97±7.49	−20.45±6.10	0.13	−3.13±1.03	−12.11±3.89	−15.53±3.64	0.029	1st p.: 0.635 2nd p.: 0.199 Wh p.: 0.530
LDL-C (mg/dL)	−7.54±3.21	10.30±7.99	−1.57±6.96	0.059	−0.38±3.42	−1.84±5.49	−3.89±5.62	0.839	1st p.: 0.137 2nd p.: 0.240 Wh p.: 0.807
Anti-HSP27 antibody	0.02 (0.01–0.03)	0.01 (0.0–0.02)	0.03 (0.02–0.04)	0.007	0.01 (−0.01–0.01)	0.01 (0.0–0.01)	0.01 (−0.01–0.02)	0.934	1st p.: 0.000 2nd p.: 0.008 Wh p.: 0.000
Anti-HSP60 antibody	0.02 (0.01–0.03)	0.01 (0.0–0.02)	0.03 (0.02–0.04)	0.040	0.01 (0.01–0.017)	0.0 (−0.01–0.01)	0.01 (−0.01–0.02)	0.003	1st p.: 0.000 2nd p.: 0.000 Wh p.: 0.000
Anti-HSP65 antibody	0.02 (0.01–0.02)	0.01 (0.01–0.02)	0.03 (0.02–0.04)	0.296	0.01 (−0.007–0.02)	0.0 (−0.01–0.017)	0.01 (0.0–0.02)	0.411	1st p.: 0.001 2nd p.: 0.009 Wh p.: 0.000
Anti-HSP70 antibody	0.02 (0.01–0.03)	0.01 (0.0–0.02)	0.03 (0.01–0.04)	0.072	0.01 (0.0–0.02)	0.01 (−0.01–0.01)	0.015 (−0.01–0.02)	0.184	1st p.: 0.001 2nd p.: 0.037 Wh p.: 0.000
hs-CRP	1.3 (0.12–2.60)	−0.69 (−2.79–0.0)	1.02 (−1.07–1.7)	0.000	1.1 (−0.03–2.11)	−0.72 (−2.89–0.2)	0.49 (−0.65–1.32)	0.004	1st p.: 0.535 2nd p.: 0.882 Wh p.: 0.566

R, Real; S, Sham; lst p., first period; 2nd p., second period; Wh p., whole period; BMI, body mass index; WC, waist circumference; HC, hip circumference; FBG, fasting blood glucose; TC, total cholesterol; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; HSP, heat shock protein; CRP, C-reactive protein. Values are expressed as mean±standard error of the mean, or median and interquartile range. Paired t-test and Wilcoxon signed-ranked test was used for comparison between first and second period for normally and non-normally distributed data, respectively. Independent sample t-test (for normally distributed data) and Mann–Whitney test (for non-normally distributed data) were used for comparison of 2 groups.

Comparison of the changes in different parameters between the case and control groups

For anthropometric parameters, authentic acupuncture was more effective for reduction in body weight in the first and whole periods of the study (p<0.01), body fat percentage in the whole period of the study (p<0.05), BMI in the first and whole period of the study (p<0.05), WC in the second and whole periods of the study (p<0.01), and HC in the all periods of the study (p<0.05). For lipid profile, no significant changes were observed.

With respect to the immunological parameters, authentic body acupuncture was more effective, since it was observed that anti-Hsp27 antibodies were significantly reduced in all three periods of the study when compared with control acupuncture (p<0.01). The same results were observed for other anti-Hsps (p<0.05). However, the marker of inflammation, hs-CRP, was not significantly changed between cases and controls (p>0.05).

Discussion

In the first period of the study, the levels of anthropometric parameters, HDL-C and hs-CRP, changed significantly in both cases and controls, while the changes in anti-Hsp antibodies were observed in cases but not controls (except anti-Hsp70 antibody). In the second period, which showed the sustained effects of acupuncture therapy, changes in anthropometric parameters were more prominent in controls when compared with the authentic acupuncture group, while the significant changes in the authentic group were observed for anti-Hsp antibodies. Moreover, hs-CRP continued to be reduced by diet restriction in both groups of cases and controls. Overall, when the whole period of the study was assessed, it was observed that in both cases and controls the anthropometric and lipid profile changed significantly, while anti-Hsp antibodies only showed significant changes in the authentic group. In addition, when comparisons were performed for the first and second period of the study in both groups, the changes for most of the parameters were more significant in the first period. Moreover, comparison between cases and controls showed that real acupuncture is more effective in reducing the levels of anthropometric factors and anti-Hsp antibodies; however, no differences were observed for the lipid profile. Nevertheless, changes in hs-CRP levels were not significantly different between the two groups. The changes in anthropometric and lipid profile in real and sham groups are shown in Figure 3.

FIG. 3.

Changes of anthropometric parameters and lipid profile in real and sham groups. BMI, body mass index; BF%, body fat percentage; WC, waist circumferences; HC, hip circumferences; TC, total cholesterol; HDL-C, high density lipoprotein-cholesterol; LDL-C, low density lipoprotein-cholesterol; TG, triglyceride. A, B and C means first, second and whole period of the study, respectively. *, ** and *** means P<0.05, P<0.01, P<0.001, respectively.

Consistent with the present study, Shafshak¹¹ found that auricular acupuncture combined with a 1000-kcal/day diet caused significant weight loss when compared with the placebo group. The same results have been found in other studies.^9,10,12 However, most of the literature on acupuncture for treatment of obesity lack control groups. Despite the above results, three studies have reported no effect of acupuncture for weight loss^25
–27; however, none of these used the combination of diet and acupuncture therapy. Acupuncture is thought to exert its effects on weight loss through different mechanisms. In terms of traditional medicine, it is believed that acupuncture alters levels of central nervous system activation by stimulating peripheral nerves at acupoints. Then, signals are carried by a stimulated nerve, resulting in changes in satiety, hunger, appetite, and mood. These mechanisms have been reviewed by Lacey et al.⁶ In an animal study, it has been reported that stimulation of the auricular regions associated with the ventromedial hypothalamus affects the satiety center and results in weight loss.²⁸ Acupuncture is also able to improve mood by increasing the release of neurotransmitters²⁹ and suppressing appetite by serotonin- and endorphin-induced decreases in stress and depression, which leads to regulation of food intake,^3,4 whereas diet or physical exercise do not affect the feeling of fullness.

With respect to the lipid profile in both cases and controls, positive changes (increase in levels of HDL-C and decrease in other parameters including triglycerides, total cholesterol, and LDL-C) were observed; however, the changes were not significant between the two groups, indicating that diet had more prominent effects on these changes rather than auricular acupuncture. Nevertheless, other studies reported different results. Li et al.³⁰ have reported significant changes in total cholesterol and LDL cholesterol during acupuncture therapy when compared with control subjects. Another study reported significant decrease of triglyceride, total cholesterol, LDL-C but not any significant changes in HDL-C levels in the acupuncture group when compared with controls.³¹ In several studies, the same pattern has been reported for changes in triglyceride, total cholesterol, LDL-C, and HDL-C as our study following acupuncture^2,32,33; however, two of these studies did not find any changes for HDL-C.^2,31 This may be explained by application of different acupoints. It has been suggested that these changes in lipid metabolism may be caused by an increase in the serum β-endorphin levels.³¹

Reduction in anti-Hsp antibodies in all periods of the study was significant only in the authentic group when compared with controls. Moreover, in the first period of the study when acupuncture combined with diet restriction, this finding was more prominent. To the authors' knowledge, no study has previously evaluated the effects of acupuncture therapy on these antibodies. While the reductions in anthropometric parameters have been observed in both groups, the decrease in anti-Hsp antibodies just in the authentic group shows that the reduction in antibody levels can be attributed to the acupuncture therapy rather than weight loss. However, it has been reported there is some evidence that dietary constituents and lipid metabolism are associated with immune response to Hsp in dyslipidemic patients,²³ as we have previously demonstrated that in high-cholesterol-fed animals, the levels of anti-Hsp antibodies increase.³⁴

It appears that acupuncture modulates and regulates the balance in the immune system.³⁵ This role is said to be explained by the interaction between the autonomic nervous system (ANS) and the immune functions and the brain as the communicator between the two systems.³⁶ By communicating with the brain, the inflammatory cytokines stimulate neural outflow via the ANS,³⁶ leading to release of acetylcholine via parasympathetic nerve (vagus) endings, resulting in neuroimmune reflex and suppressing the release of inflammatory cytokines.³⁶

In addition, reductions in hs-CRP levels were seen in different periods of the study in both groups. Interestingly, the analysis showed that changes in hs-CRP levels were not different between cases and controls, implying that hs-CRP changed independent of the effects of acupuncture. There is evidence that demonstrates the fact that elevated CRP levels are closely related to obesity.¹⁶ It has been also suggested that adipose tissue releases the pro-inflammatory cytokines,³⁷ so it is logical that weight loss is associated with decrease in CRP levels. Other studies have found the same result as in the present study about the reduction in CRP levels following weight loss.^19,20

Conclusions

In conclusion, acupuncture therapy in combination with diet restriction was found to be effective for weight loss and also reduction of the obesity-associated risks factors, such as dyslipidemia. However, these effects can be achieved by other interventions, but due to lack of adverse events and continued effects after the therapy, acupuncture could be used as a preferred or synergic treatment option for obesity control. Moreover, it was found that it has immunomodulatory but not anti-inflammatory effects on the immune system by regulation of the levels of anti-Hsp antibodies.

Footnotes

Acknowledgments

We are particularly grateful to the patients and their family members who volunteered to participate in this study. This work was supported by the Iranian Ministry of Health and Education, Mashhad University of Medical Science (MUMS), Iran and Beijing University of Chinese Medicine, China. The results presented in this work have been taken from Hamid Abdi's thesis in Mashhad University of Medical Science, with the following ID number: 86058.

Disclosure Statement

The authors declare no conflict of interest.

References

Clinical guidelines on the identification, evaluation, treatment of overweight, obesity in adults: The evidence report. National Institutes of Health. Obes Res, 1998; 6,suppl 2:51S–209S.

Sun

, Xu

. Simple obesity and obesity hyperlipemia treated with otoacupoint pellet pressure and body acupuncture. J Tradit Chin Med, 1993; 13:22–26.

Akil

, Watson

, Young

et al. Endogenous opioids: Biology and function. Annu Rev Neurosci, 1984; 7:223–255.

Wenhe

, Yucun

. Change in levels of monoamine neurotransmitters and their main metabolites of rat brain after electric acupuncture treatment. Int J Neurosci, 1981; 15:147–149.

Zijlstra

, van den Berg-de

Lange

, Huygen

, Klein

. Anti-inflammatory actions of acupuncture. Mediators Inflamm, 2003; 12:59–69.

Lacey

, Tershakovec

, Foster

. Acupuncture for the treatment of obesity: A review of the evidence. Int J Obes Relat Metab Disord, 2003; 27:419–427.

Cabyoglu

, Ergene

, Tan

. The treatment of obesity by acupuncture. Int J Neurosci, 2006; 116:165–175.

Huang

, Yang

, Hu

. Preliminary results of triple therapy for obesity. Int J Obes Relat Metab Disord, 1996; 20:830–836.

Lei

. Treatment of 42 cases of obesity with acupuncture. J Tradit Chin Med, 1988; 8:125–126.

10.

Mulhisen

, Rogers

. Complementary and alternative modes of therapy for the treatment of the obese patient. J Am Osteopath Assoc, 1999; 99:S8–S12.

11.

Shafshak

. Electroacupuncture and exercise in body weight reduction and their application in rehabilitating patients with knee osteoarthritis. Am J Chin Med, 1995; 23:15–25.

12.

Zhan

. Observations on the treatment of 393 cases of obesity by semen pressure on auricular points. J Tradit Chin Med, 1993; 13:27–30.

13.

Ghayour-Mobarhan

, Rahsepar

, Tavallaie

et al. The potential role of heat shock proteins in cardiovascular disease: Evidence from in vitro and in vivo studies. Adv Clin Chem, 2009; 48:27–72.

14.

Wick

, Schett

, Amberger

et al.

Is atherosclerosis an immunologically mediated disease?

Immunol Today, 1995; 16:27–33.

15.

Atar

, Gulmez

, Atar

et al. The effects of prior beta-blocker therapy on serum C-reactive protein levels after percutaneous coronary intervention. Clin Cardiol, 2005; 28:243–246.

16.

Lemieux

, Pascot

, Prud'homme

et al. Elevated C-reactive protein: Another component of the atherothrombotic profile of abdominal obesity. Arterioscler Thromb Vasc Biol, 2001; 21:961–967.

17.

Mora

, Lee

, Buring

, Ridker

. Association of physical activity and body mass index with novel and traditional cardiovascular biomarkers in women. JAMA, 2006; 295:1412–1419.

18.

Visser

, Bouter

, McQuillan

et al. Elevated C-reactive protein levels in overweight and obese adults. JAMA, 1999; 282:2131–2135.

19.

Heilbronn

, Noakes

, Clifton

. Energy restriction and weight loss on very-low-fat diets reduce C-reactive protein concentrations in obese, healthy women. Arterioscler Thromb Vasc Biol, 2001; 21:968–970.

20.

Tchernof

, Nolan

, Sites

et al. Weight loss reduces C-reactive protein levels in obese postmenopausal women. Circulation, 2002; 105:564–569.

21.

Siervo

, Boschi

, Falconi

. Which REE prediction equation should we use in normal-weight, overweight and obese women? Clin Nutrition, 2003; 22:193–204.

22.

Lustig

, Sen

, Soberman

, Velasquez-Mieyer

. Obesity, leptin resistance, and the effects of insulin reduction. Int J Obes Relat Metab Disord, 2004; 28:1344–1348.

23.

Ghayour-Mobarhan

, New

, Lamb

et al. Dietary antioxidants and fat are associated with plasma antibody titers to heat shock proteins 60, 65, and 70 in subjects with dyslipidemia. Am J Clin Nutr, 2005; 81:998–1004.

24.

Ghayour-Mobarhan

, Sahebkar

, Parizadeh

et al. Antibody titres to heat shock protein 27 are elevated in patients with acute coronary syndrome. Int J Exp Pathol, 2008; 89:209–215.

25.

Allison

, Kreibich

, Heshka

, Heymsfield

. A randomised placebo-controlled clinical trial of an acupressure device for weight loss. Int J Obes Relat Metab Disord, 1995; 19:653–658.

26.

Mazzoni

, Mannucci

, Rizzello

et al. Failure of acupuncture in the treatment of obesity: A pilot study. Eat Weight Disord, 1999; 4:198–202.

27.

Mok

, Parker

, Voina

, Bray

. Treatment of obesity by acupuncture. Am J Clin Nutr, 1976; 29:832–835.

28.

Asamoto

, Takeshige

. Activation of the satiety center by auricular acupuncture point stimulation. Brain Res Bull, 1992; 29:157–164.

29.

Han

, Terenius

. Neurochemical basis of acupuncture analgesia. Annu Rev Pharmacol Toxicol, 1982; 22:193–220.

30.

, Wang

. Clinical therapeutic effects of body acupuncture and ear acupuncture on juvenile simple obesity and effects on metabolism of blood lipids [in Chinese] Zhongguo Zhen Jiu, 2006; 26:173–176.

31.

Cabioglu

, Ergene

. Electroacupuncture therapy for weight loss reduces serum total cholesterol, triglycerides, and LDL cholesterol levels in obese women. Am J Chin Med, 2005; 33:525–533.

32.

Wang

, Xu

, Xiao

. Effect of high-frequency electroacupuncture on lipid metabolism in obesity rats [in Chinese] Zhen Ci Yan Jiu, 2008; 33:154–158.

33.

Liu

, Sun

, Li

et al. Prophylactic and therapeutic effects of acupuncture on simple obesity complicated by cardiovascular diseases. J Tradit Chin Med, 1992; 12:21–29.

34.

Ghayour-Mobarhan

, Lamb

, Tavallaie

, Ferns

. Relationship between plasma cholesterol, von Willebrand factor concentrations, extent of atherosclerosis and antibody titres to heat shock proteins-60, −65 and −70 in cholesterol-fed rabbits. Int J Exp Pathol, 2007; 88:249–255.

35.

Mori

, Nishijo

, Kawamura

, Abo

. Unique immunomodulation by electro-acupuncture in humans possibly via stimulation of the autonomic nervous system. Neurosci Lett, 2002; 320:21–24.

36.

Tracey

. The inflammatory reflex. Nature, 2002; 420:853–859.

37.

Yudkin

, Stehouwer

, Emeis

, Coppack

. C-reactive protein in healthy subjects: Associations with obesity, insulin resistance, and endothelial dysfunction. A potential role for cytokines originating from adipose tissue? Arterioscler Thromb Vasc Biol, 1999; 19:972–978.