Acupuncture Treatment For Obesity:
A Randomized Controlled Trial
Kay Keng Khoo, MD

ABSTRACT
Background The prevalence of obesity has increased alarmingly worldwide in recent decades and has assumed epidemic proportion. Where conventional therapies fail to reduce weight effectively, people are increasingly seeking alternative therapy such as acupuncture.
Objective To study the efficacy of acupuncture treatment in enhancing weight loss in patients on a diet and exercise regimen.
Design, Setting, and Participants A prospective, randomized controlled trial of 30 obese patients (minimum age, 20 years; body mass index [BMI] Ž30) attending a general practice clinic in Australia. Patients in the control group (n=15) followed a diet and exercise regimen, and patients in the intervention group (n=15) received acupuncture treatments as well as following the same diet and exercise regimen for 5 weeks.
Intervention Acupuncture points used were PC 6 and ST 36; a small Acu-patch press sphere was taped over the hunger point in front of the tragus of the ear. Participants in both groups were instructed to follow a reduced-intake diet and exercise regimen.
Main Outcome Measures Patients' weight and BMI were measured at baseline and at the conclusion of the trial.
Results The intervention and control groups were matched for age, initial weight, and BMI. The total weight loss in the control group was 36 kg, averaging a weight loss of 2.4 kg or 2.5% of body weight. The corresponding figures for the intervention group were 72 kg, averaging 4.8 kg or 5% of body weight. The difference in absolute weight loss was statistically significant (P=.006).
Conclusions Further studies are required to confirm this finding of enhanced weight loss in patients receiving acupuncture along with a diet regimen of reduced energy intake and increased energy expenditure.
KEY WORDS
Acupuncture, Obesity, Diet, Exercise, Weight Loss, Body Mass Index, Randomized Controlled Trial

INTRODUCTION
A study that surveyed the prevalence of obesity and diabetes in Australia between 1999 and 2000 demonstrated a prevalence of overweight and obesity in both sexes of almost 60%. The prevalence of overweight was 39.0% and that of obesity was 20.8%. The prevalence of obesity has increased 2.5 times over that of 2 decades ago. Over the same period in the United States, the prevalence of obesity doubled from 15.0% to 30.9%.¹ Where conventional weight loss therapies fail to deliver results, people are increasingly willing to seek alternative therapy for weight loss. Controlled trials that measured the effect of acupuncture alone without diet restrictions gave conflicting results on the efficacy of acupuncture for weight loss.^2-4 The present study aimed to establish whether acupuncture further enhances the efficacy of a reduced energy intake and increased energy expenditure regimen for weight reduction.

METHODS
Patients and Study Design
Thirty obese patients, all at least 20 years old, were recruited from a general practice clinic in Australia. Those who weighed more than 120 kg, were younger than 20 years old, had debilitating diseases, or had received acupuncture treatments in the previous 3 months were excluded. Those whose body mass index (BMI) was 30 or higher and who did not meet exclusion criteria were recruited. All patients gave their consent to participate in this study.
Fifteen randomly chosen control patients were instructed to follow a diet regimen consuming two-thirds of their usual dietary intake and limiting their fat intake to 50 g/d over a period of 5 weeks. Each patient was given a pocket-sized book, "Fat and Cholesterol Counter" (AMRAD Pharmaceuticals Pty Ltd, Victoria, Australia). They were shown how to count the fat contents in each item of food ingredient on the plate.

They were asked to follow an aerobic exercise regimen of walking, bicycling, or swimming for 20-30 minutes 3 times a week. Fifteen randomly chosen intervention patients followed a similar diet and exercise regimen and were also given twice-weekly acupuncture treatments for 20 minutes over a similar 5-week period.

Treatment
Bilateral acupuncture points used were PC 6 (chosen to relieve anxiety associated with overeating in obesity), and ST 36; used also was a small Acu-patch 1.2-mm stainless steel press sphere on high-quality adhesive tape (Acuneeds Australia, Victoria, Australia) taped over the hunger point in front of the tragus of the ears. The patients were asked to press on the spheres for 1 minute upon waking, before each meal or snack, as well as at morning and afternoon tea. Acupuncture needles of gauge 0.25 mm and length 13 mm with traditional filiform-wound copper handles were used. All patients were reviewed once a week regarding their adherence to the diet and exercise regimens, and any questions or difficulties were discussed.

Statistical Analyses
The relative and absolute weight loss were each compared between groups using the Mann-Whitney U test, which is a nonparametric statistical significance test appropriate to the case of 2 independent samples of observations to determine whether the degree of overlap be-
tween the 2 observed distributions is less than would be expected by chance. Analyses were conducted using the S-PLUS statistical package.

RESULTS
Patient characteristics and results of the trial are tabulated in Table 1. The study came to an end when 30 patients within the stated criteria completed the study, 15 in the intervention group and another 15 in the control group. In addition to these 30 patients, there were 5 patients who did not complete the observation. Two patients in the control group did not complete the study; 1 stopped after 3 weeks due to a perianal infection while the other was lost to follow-up after 1 week. Three patients in the intervention group did not complete the study: 1 patient discontinued due to personal reasons, the 2nd patient was lost to follow-up after 3 weeks, and the 3rd patient had infection in both feet.

Descriptive statistics showed a trend toward greater weight loss in the intervention group for both relative weight loss (weight loss divided by baseline weight) and absolute weight loss (baseline weight minus follow-up weight) (Table 2).

The intervention and control groups were equally matched for age, initial weight, and BMI (Tables 3 and 4). The total weight loss in the intervention group was 72 kg while that of the control group was 36 kg. The difference between the average weight loss of 4.8 kg or 5% of body weight per patient in the intervention group, and the corresponding figures of 2.4 kg or 2.5% in the control group, was statistically significant.

The majority of patients in both groups had lipid profiles determined: 1 patient in the acupuncture group and 2 patients in the control group received statin treatment for dyslipidemia. There were 3 patients with diabetes, 3 with hypothyroidism, and 7 with hypertension in the control group. There was 1 patient with diabetes, 1 with impaired glucose tolerance, 1 with hypothyroidism, and 4 with hypertension in the acupuncture group. All patients with systemic diseases received regular laboratory investigation follow-up and appropriate therapies.

Since all patients were recruited from a general practice clinic, all patients with systemic diseases such as hypertension, diabetes, and hypothyroidism received the appropriate medical treatments, including statins for abnormal lipid profiles, and were regularly monitored with laboratory investigations to follow the progress of treatments. Lipid profiles were not performed to monitor the effects of acupuncture in changing lipid profiles.

Table 1. Patient Characteristics and Main Outcomes
	Control Group	Intervention Group
Men/women	4/11	3/12
Age, mean (range), y	50 (24-79)	48 (25-67)
Weight, mean (range), kg	95.4 (78-120)	95.5 (77-118)
Body mass index,
mean (range)	35.2 (30.1-43.9)	35.2 (30.1-43.9)
Weight loss, kg
Total	36.00	72.00
Average	2.40	4.80
% of total weight lost	2.50	5.00

Table 2. Relative and Absolute Weight Loss by Group
Relative Weight Loss, %	Intervention	Control	Difference
Mean	4.92	2.41	2.51
Median	5.32	1.82	3.50
Mann-Whitney P value	0.00	0.01
Absolute Weight Loss, kg	Intervention	Control	Difference
Mean	4.80	2.40	2.40
Median	5.00	2.00	3.00

Table 3. Individual Weight Changes in the Control Group
Patient	Height,			Weight, kg	Weight
Sex/Age, y	cm	BMI	Baseline	Follow-up	Loss, kg
M/26	186.00	31.79	110.00	103	7
F/79	152.00	33.76	78.00	78	0
M/51	175.00	35.94	110.00	109	1
M/29	176.00	38.71	120.00	115	5
M/57	169.00	33.61	96.00	95	1
F/68	168.00	30.14	85.00	84	1
F/35	156.00	33.74	82.00	78	4
F/61	160.00	31.25	80.00	79	1
F/68	159.00	35.21	89.00	86	3
F/24	161.00	42.85	110.00	108	2
F/37	157.00	32.92	81.00	79	2
F/61	164.00	43.86	118.00	113	5
F/52	161.00	33.97	88.00	87	1
F/42	167.00	36.21	101.00	100	1
F/55	155.00	34.58	83.00	81	2
Mean overall		35.24	95.40	93	2.4
Abbreviation: BMI, body mass index; calculated as weight in kilograms divided by height in meters squared.

Table 4. Individual Weight Changes in the Intervention Group
Patient	Height,			Weight, kg	Weight
Sex/Age, y	cm	BMI	Baseline	Follow-up	Loss, kg
F/50	158.00	42.81	107.00	98	9
F/57	155.00	38.75	93.00	89	4
F/44	162.00	30.08	77.00	74	3
F/53	175.00	35.94	110.00	102	8
F/52	164.00	31.34	84.00	79	5
F/49	167.00	31.91	89.00	84	5
F/67	163.00	30.07	80.00	77	3
F/51	164.00	43.86	118.00	111	7
M/44	169.00	34.26	98.00	94	4
M/55	179.00	36.25	116.00	111	5
M/25	173.00	33.78	101.00	95	6
F/51	156.00	37.03	90.00	90	0
F/49	153.00	34.18	87.00	85	2
F/27	175.00	30.71	94.00	89	5
F/48	155.00	37.08	89.00	83	6
Mean overall		35.20	95.50	90.7	4.8
Abbreviation: BMI, body mass index; calculated as weight in kilograms divided by height in meters squared.

DISCUSSION
While there are numerous studies on acupuncture treatments for obese patients, there are more reports than there are controlled trials.

Two randomized controlled trials in which the patients received auricular acupuncture to induce weight loss reported negative outcomes. Ninety-six participants were involved in one trial, in which treatment patients wore the Acu-Stop 2000, an acupressure device, to stimulate auricular acupuncture points for 12 weeks; the controls wore an acupressure device on their wrists that had no acupuncture points for weight loss. The device was placed by the patient and massaged for 2-3 minutes several times a day. There was no significant weight loss between the treatment and control groups. The average weight loss per patient was 0.96 kg.² In another randomized controlled trial of 24 obese participants using auricular acupuncture for 9 weeks, no difference in weight loss between the treatment and control groups was recorded.³

In another randomized controlled trial of 60 overweight patients, treatment participants wore the AcuSlim device (consisting of a battery-operated pack) on the ears, while the controls wore the AcuSlim device on their thumbs, for 15-20 minutes twice daily for 4 weeks. The average weight loss of 2.98 kg in 28 treatment patients was significantly better than that of 0.63 kg in 32 controls.⁴ These 3 trials measured the effects of acupuncture alone without dietary restrictions on weight reduction and came up with conflicting results.

In another randomized controlled trial of 20 obese women, all followed a diet of 2000 calories/d and walked 15 minutes each day. Ten treatment participants received weekly ear acupuncture at specific points for 8 weeks; 10 controls did not receive acupuncture. Mean weight loss of 4.09 kg in the treatment group was significantly better than the mean weight loss of 1.82 kg in the control group.⁵

Waist circumference is equally important as BMI as a parameter of obesity.⁶ However, the abrupt alteration of waist circumference by liposuction does not improve obesity-associated metabolic abnormalities or improve cardiovascular risk factors.⁷

CONCLUSIONS
The average weight loss per patient was 2.40 kg in the control group and 4.80 kg in the intervention group. The results are consistent with the effectiveness of acupuncture treatment in further enhancing weight loss in patients already following a diet and exercise regimen for weight loss. Effective measures to promote weight reduction are important not only because obesity has become a global epidemic, but also because it is a significant risk factor for several important systemic diseases and contributes to morbidity and mortality.8 Exercise not only enhances weight loss by increasing energy expenditure, but it has protective metabolic effects in preventing onset of type 2 diabetes mellitus.^9,10

The weight loss achieved in patients following a regimen of reduced energy intake and increased energy expenditure is further enhanced by the administration of acupuncture treatment. Further large-scale studies are required to confirm this preliminary finding.

ACKNOWLEDGEMENT
The assistance of Heath Peterson in the statistical analysis is gratefully acknowledged.

REFERENCES

1. Cameron AJ, Welborn TA, Zimmet PZ, et al. Overweight and obesity in Australia: the 1999-2000 Australian Diabetes, Obesity and Lifestyle Study (AusDiab). Med J Aust. 2003;178(9):427-432.
2. Allison DB, Kreibich K, Heshka S, et al. A randomized placebo-controlled clinical trial of an acupressure-device for weight loss. Int J Obes. 1995;19: 653-658.
3. Mok MS, Parker LN, Voina S, et al. Treatment of obesity by acupuncture. Am J Clin Nutr. 1976;29:832-835.
4. Richards D, Marley J. Stimulation of acupuncture points in weight loss.  Aust Fam Phys. 1998;27(suppl 2):S73-S77.
5. Kuruvilla AC. Acupuncture and obesity. Medical Acupuncture. 2003;14(2): 121-122.
6. Egger G, Binns A. A modern approach to obesity. Med Today. October 2001:
   39-46.
7. Klein S, Fontana J, Young L, et al. Absence of an effect of liposuction on insulin action and risk factors for coronary heart disease. N Engl J Med. 2004;350:2549-2557.
8. World Health Organization. Obesity: Preventing and Managing the Global Epidemic. Geneva, Switzerland: WHO; 2000:256. WHO technical report 894.
9. Helmrich SP, Ragland DR, Leung RW, et al. Physical activity and reduced occurrence of non-insulin dependent diabetes mellitus. N Engl J Med. 1991; 325:147-152.
10. Tuomilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001;344:1343-1350.

AUTHOR INFORMATION
Dr Kay Keng Khoo is principal Family Physician at a private medical clinic in Australia, Fellow of the Royal College of Physicians of Edinburgh, and West Australian State President of the Australian Medical Acupuncture College.
Kay Keng Khoo, MB (MD), BS, MRCP(UK), FRCP(Edin), FAMAC*
Lynwood Medical Centre
625 Metcalfe Rd
Lynwood, WA 6147
Australia
Phone: 08-9451-2800 • Fax: 08-9451-2921 • E-mail: kkkhoo99@yahoo.com

*Correspondence and reprint requests

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