Nutritional and metabolism

The effects of auricular acupuncture on

weight reduction and feeding-related
cytokines: a pilot study
Hisayuki Ito,1 Osamu Yamada,2 Yuji Kira,3 Takeshi Tanaka,4 Rumiko Matsuoka5

To cite: Ito H, Yamada O, ABSTRACT

Kira Y, et al. The effects of Summary box
Objective: Auricular acupuncture is a common
auricular acupuncture on
therapy used to control appetite; however, the What is already known about this subject?
weight reduction and feeding-
related cytokines: a pilot
underlying mechanism(s) of action is unclear. The Previous studies suggest that the weight reduc-
study. BMJ Open Gastro present study examined changes in feeding behaviour tion effect of auricular acupuncture occurs via
2015;2:e000013. and in the levels of several appetite-related hormones the vagus nerve.
doi:10.1136/bmjgast-2014- in response to auricular acupuncture, and attempted to However, these different experimental models
000013 identify the mechanism(s) by which this traditional have not provided definitive answers regarding
medical treatment exerts its effects. treatment efficacy or the underlying mechanism
Methods: Ten healthy adult volunteers (nine female of action.
Received 3 August 2014 and one male) were recruited by the KOSAI Oriental The acupuncture sites used in this study lie
Revised 3 November 2014 Healthcare Center. The participants were randomly along the auricular branch of the vagus nerve
Accepted 23 November 2014 assigned to one of two groups (n=5 per group): an (Arnolds nerve), which is its only somatosen-
acupuncture group and a placebo group. Each received sory branch.
detention needle stimulus on a weekly basis for
1 month. Changes in diet, body weight, blood pressure What are the new findings?
and blood biochemistry were evaluated before This study examined changes in body weight
treatment and at 1 week after the start of treatment. and in the levels of several appetite-related pep-
Results: The difference in weight before treatment and tides in response to auricular acupuncture.
after 1 week of treatment was significant for all We found that the increase in early morning
participants in the acupuncture group ( p=0.02). fasting ghrelin levels in the acupuncture group
The percentage changes in active ghrelin in the was suppressed after 1 week of auricular acu-
acupuncture group were no significant changes puncture treatment, whereas all of the partici-
observed in active ghrelin levels at 1 week after pants in the placebo group showed an increase
acupuncture in any individual participant ( p=0.89). in early morning fasting ghrelin levels.
By contrast, the percentage changes in active ghrelin Despite the small sample sizes, the results
levels in the placebo group at 1 week after the start of suggest that all participants in the auricular acu-
acupuncture were significant ( p=0.04). The insulin, puncture group experienced weight loss during
adrenocorticotropic hormone, leptin and adiponectin week 1 of the study.
levels did not change significantly in either group. How might it impact on clinical practice in
Conclusions: There was a statistically significant the foreseeable future?
difference in the percentage change in body weight and Although this study is preliminary and the
active ghrelin levels in each individual participant in number of cases is small, it is suggested that
auricular acupuncture groups. This is a pilot study and the results provide a scientific basis for the
1
KOSAI Oriental Healthcare the sample number is small; however, auricular effect of acupuncture on appetite.
Center, Tokyo, Japan acupuncture may reduce appetite by suppressing
2
Faculty of Health Care,
ghrelin production.
Teikyo Heisei University,
Tokyo, Japan
3
Showa General Hospital, accumulation, and overconsumption of cal-
Tokyo, Japan ories and a lack of exercise are problems for
4
Department of Research
Support, Tokyo Womens
INTRODUCTION people in the busy modern world. Auricular
Medical University, Tokyo, The increasing prevalence of lifestyle-asso- acupuncture, a traditional form of medicine
Japan ciated diseases is linked to an increased inci- practised worldwide, can suppress the appe-
5
Wakamatsu Kawada Clinic, dence of arteriosclerotic conditions such as tite, although in the West it is also used for
Tokyo, Japan cerebral infarction and myocardial infarc- pain relief1 and to treat drug addiction2 and
Correspondence to tion, which pose a major problem from a anxiety.3
Dr Osamu Yamada; medical and an economic point of view. Appetite suppression in response to acu-
yamadao@thu.ac.jp Overeating is a major cause of visceral fat puncture has been studied in rats, mice and

Ito H, Yamada O, Kira Y, et al. BMJ Open Gastro 2015;2:e000013. doi:10.1136/bmjgast-2014-000013 1

Open Access

humans; however, these different experimental models

have not provided denitive answers regarding treat-
ment efcacy or the underlying mechanism(s) of
action.4 Progress is being made in understanding the
mechanisms that regulate appetite, and several
appetite-regulatory peptides were recently identied.5
Previous studies suggest that the weight reduction
effect of auricular acupuncture occurs via stimulation of
the hunger and stomach points.6 Anatomically, the
hunger point is located in the tragus, and the stomach
point is located in the cuvum conchae, with both points
falling within the distribution of the auricular branch of
the vagus nerve. This study examined changes in feeding
behaviour and in the levels of several appetite-related
hormones in response to auricular acupuncture, and also
attempted to identify the mechanism(s) by which this
Figure 1 Acupuncture stimulation sites (hunger point and
traditional medical treatment exerts its effects.
stomach point) For the acupuncture group, indwelling
intradermal needles were placed at the indicated sites
(arrows) and fixed in position with medical tape. For the
MATERIALS AND METHODS
placebo group, intradermal needles were fixed with medical
Subjects tape, but did not pierce the skin.
Ten healthy adult volunteers (nine female and one male;
median age, 40 years (range, 2444 years)) comprising points were selected and treatment was performed by a
students, ofce workers and housewives were recruited at certied and experienced Japanese acupuncturist at the
the KOSAI Oriental Healthcare Center. The participants KOSAI Oriental Healthcare Center.
were randomly assigned to one of two groups (n=5 per For the acupuncture group, the acupuncture site was
group), an acupuncture group and a placebo group, cleaned with ethanol and an intradermal needle (3 mm
using sealed envelopes. None of the participants had an in length, 0.12 mm in diameter; Seirin, Japan) was
endocrine disease or a history of diabetes, heart disease, inserted horizontally to a depth of approximately 1
allergy or immunological disease, or stroke. None were 2 mm. Needles were inserted bilaterally. The needles
pregnant or lactating, or had given birth within the past were xed with medical tape and left in position for
6 months, and all had been able to exercise to manage 1 week. All needles were replaced on a weekly basis for a
their weight within the past 3 months. Written consent period of 4 weeks. A new session began immediately
was obtained from all participants after the study objec- after the needle was replaced. For the placebo group,
tives, methods and safety issues were clearly and fully the intradermal needle was xed with medical tape but
explained. The study protocol was approved by the did not pierce the skin. Only the acupuncturist was
Human Investigation Committee of the KOSAI Oriental aware of the group into which each participant had
Healthcare Center. All participants were free to withdraw been assigned. The participants all rmly believed that
from the study at any time. they were receiving auricular acupuncture stimulation.
At no point were the participants told whether or not
Acupuncture they had received auricular acupuncture. The same acu-
Common auricular points used for the treatment of puncture points were used for all participants, and all
obesity include the hunger and stomach points, which received acupuncture treatment once per week for four
regulate satiety and fullness.7 The hunger and stomach consecutive weeks (ie, four sessions) at the KOSAI
points were located using a Chinese auriculotherapy Oriental Healthcare Center.
chart8 and Nogiers somatotopic inversion (gure 1).9
The precise locations of the acupuncture sites were iden- Observations
tied using a Tormeter IW-ZEN device (Model 5505; Observations were conducted on a weekly basis for four
Kuga Denshikiki Seisakusho, Japan), which measures consecutive weeks. Body weight, waist circumference and
autonomic nerve activity. This device detects zones of low body mass index (BMI) were recorded before the start
electrical resistance in the skin; these zones correspond of the study and then on a weekly basis thereafter. Both
to acupuncture points.10 Briey, the auriculotherapy elec- groups kept a record of their diet during the study and
trode (tip diameter, 1.0 mm) was used to measure elec- a dietician assessed the food intake of each participant
trical resistance at the hunger point in the tragus and from pictures taken with a digital camera. No subjective
within the distribution of the auricular branch of the measures were performed; however, changes in diet and
vagus nerve above the auricle (where the stomach point food intake were monitored through the dieticians
is located). The site with the least electrical resistance was records. Both groups were instructed to carry on as
used as the acupuncture point. Auricular acupuncture normal during the observation period, although they

2 Ito H, Yamada O, Kira Y, et al. BMJ Open Gastro 2015;2:e000013. doi:10.1136/bmjgast-2014-000013

 Open Access

were not allowed to receive acupuncture or to take any (participants FJ) was 35 years (range, 2443 years). The
medications. acupuncture group comprised four women and one man,
and the placebo group comprised ve women. The
Urinalysis and blood tests median body weight in the acupuncture group was 62.4 kg
Fasting urine and blood samples were collected by a (range, 55.894.7 kg) and that in the placebo group was
medical doctor at Tokyo Womens Medical University 60.2 kg (range, 5382 kg; table 1). No abnormal haematol-
before the study began and again after 1 week of acu- ogy, blood biochemistry or lipid results were recorded for
puncture treatment (before the needle was replaced). either group.
Samples were collected early in the morning before
breakfast (between 6:30 and 8:00). A new acupuncture Changes in body weight
session began after the blood sample was collected. Figure 2 shows body weight before the study and after
In addition to general urinalysis, blood biochemistry 1 week of treatment for all participants in the acupunc-
and haematological tests were performed and the con- ture group. Participant A lost 2.6 kg, which was the
centrations of insulin, C-peptide, leptin, adiponectin, largest percentage change (3.5%). The percentage
adrenocorticotropic hormone (ACTH), active ghrelin changes in body weight for participants B, C, D, and E
and desacyl-ghrelin were measured. Blood ghrelin con- were 0.7%, 2.6%, 3%, and 1%, respectively. The
centrations were measured using active ghrelin ELISA difference in weight before treatment and after 1 week
and desacyl-ghrelin ELISA kits (SCETI, Japan). All tests of treatment was signicant for all participants in the
were performed by Mitsubishi Chemical Medience acupuncture group ( p=0.02).
( Japan). The percentage changes in the levels of The percentage changes in body weight for partici-
appetite-regulating factors were calculated as follows: pants in the placebo group over the same period were
((value after acupuncturevalue before acupuncture)/ +1.3% ( participant F), +0.3% ( participant I) and 0%
value before acupuncture)100, where before acupunc- ( participants G, H, and J). These changes were not sig-
ture: before the study began, and after acupuncture: after nicant ( p=0.18).
1 week and immediately before a new session began.

Statistical analysis Changes in appetite-regulatory peptide levels

SAS software (V.9.1; SAS Institute, USA) was used for all Tables 2 and 3 show the levels of biochemistry and
statistical analyses. A paired t test was used to compare appetite-regulatory peptides before treatment and at
changes in body weight and changes in the levels of 1 week after the start of treatment. There were no clear
appetite-regulatory peptides both before the study and differences in the fasting blood sugar, insulin, ACTH,
at 1 week after the start of acupuncture. A p value <0.05 adiponectin or leptin levels between the two groups.
was considered signicant. Figure 3 shows the percentage changes in active ghrelin
levels 1 week after the start of acupuncture (with respect
to baseline levels). The percentage changes in active
RESULTS ghrelin in the acupuncture group were 28% ( partici-
Participant characteristics and general test results pant A), +11% ( participant B), +20% ( participant C),
The median age of the participants in the acupuncture 19% ( participant D) and +2% ( participant E), with no
group (participants AE) was 43 years (range, 4044 signicant changes observed in active ghrelin levels at
years) and that of the participants in the placebo group 1 week after acupuncture in any individual participant

Table 1 Physical findings

Height Weight Waist circumference Blood pressure Heart rate
Case Age Sex (cm) (kg) BMI (cm) (mm Hg) (bpm)
Acupuncture group
A 44 F 169 74.9 26.3 85 112/90 61
B 44 F 156 55.8 23 75.1 120/73 67
C 43 F 156 58.3 23.8 82 101/72 62
D 40 F 159 62.4 24.5 80.3 116/80 72
E 40 M 173 94.7 31.7 106.2 136/95 72
Placebo group
F 24 F 172.5 60.2 20.3 79 113/81 72
G 34 F 161 54.4 20.8 68.2 110/73 84
H 43 F 159 53 21 76.1 95/57 66
I 43 F 157.8 65.2 26.4 86.2 117/71 85
J 35 F 170 82 28.4 97 117/59 76
BMI, body mass index.

Ito H, Yamada O, Kira Y, et al. BMJ Open Gastro 2015;2:e000013. doi:10.1136/bmjgast-2014-000013 3

Open Access

sizes, the results suggest that all participants in the auricu-

lar acupuncture group experienced weight loss during
week 1 of the study. However, the sample was heteroge-
neous with respect to BMI. Therefore, future studies
should examine the inuence of acupuncture in groups
of individuals of different body weight (ie, normal, over-
weight and obese individuals).
The mechanism(s) underlying the weight loss
observed after auricular acupuncture remains unclear,
although the vagus nerve is thought to be involved.13
The acupuncture sites used in this study lie along the
auricular branch of the vagus nerve (Arnolds nerve),
which is its only somatosensory branch. Animal studies
investigating the relationship between acupuncture and
gastric peristalsis and feeding have been conducted.14
For example, Shiraishi et al investigated the effects of
auricular acupuncture on neuronal activity in the
feeding centre (lateral hypothalamic area: LHA) in a rat
Figure 2 Percentage change in body weight at 1 week after model of simple obesity, and on neuronal activity in the
the start of acupuncture treatment. Black columns denote the satiety centre (ventromedial nucleus of the hypothal-
acupuncture group (AE) and grey columns denote the amus: HVM) in a rat model of hypothalamic obesity (in
placebo group (FJ). The percentage change in body weight which the satiety centre was disrupted). Using electro-
was calculated as follows: ((value after stimulationvalue
physiological techniques, they found that auricular acu-
before stimulation)/value before stimulation)100 (%).
A significant reduction in body weight was observed for all
puncture stimulates the LHA via the auricular branch of
members of the acupuncture group ( p=0.02). the vagus nerve and inhibits the excitability of LHA
neurons. They also reported evidence of signal transduc-
tion between the auricle and the hypothalamus, and
( p=0.89). In contrast, the percentage changes in active noted that auricular acupuncture increased the activity
ghrelin levels in the placebo group at 1 week after the of HVM neurons, thereby contributing to the induction
start of acupuncture were +434% ( participant F), +14% or maintenance of satiety.15 In addition, Asamoto et al16
( participant G), +149% ( participant H), +64% ( partici- reported that auricular acupuncture increased HVM
pant I) and +29% ( participant J); all of these were sig- neuronal activity in rats, which led to a reduction in
nicant ( p=0.04). The leptin and adiponectin levels did body weight. Therefore, auricular acupuncture may also
not change signicantly in either group. The dietician suppress LHA neuronal activity via an afferent pathway
assessed reductions in food intake by estimating the of the vagus nerve and activate HVM neuronal activity in
nutritional value of each meal from photographs. humans, which may lead to decreased food intake and
subsequent weight loss.
Adverse effects In humans, the effects of auricular acupuncture often
No major adverse effects were observed during the manifest as changes in body weight17 and subcutaneous
study, and none of the participants withdrew from the fat levels,18 as assessed by modalities such as CT scan. In
study due to discomfort associated with the treatment. this study, we also measured the levels of appetite-
regulatory peptides. We found that the increase in early
morning fasting ghrelin levels in the acupuncture group
DISCUSSION was suppressed after 1 week of acupuncture, whereas all
Auricular acupuncture therapy has been practised in of the participants in the placebo group showed an
China since ancient times; however, it has become inter- increase in early morning fasting ghrelin levels. The
nationally recognised due to the work of the French phys- serum ghrelin level change is affected by blood glucose
ician Paul Nogier.11 Acupuncture is widely used to treat and insulin levels.19 The changes in blood glucose and
many symptoms/conditions, and auricular acupuncture insulin levels were not signicantly different between the
is the method most often used to treat obesity.12 acupuncture and placebo groups. The mechanism
The objective of this study was to identify the mechan- underlying this phenomenon may involve the inter-
ism(s) by which auricular acupuncture therapy sup- action between feeding-related cytokines and the vagus
presses appetite in humans. To this end, we enrolled 10 nerve. Since the vagus nerve controls peristalsis, its
volunteers: 5 had an indwelling intradermal needle nerve endings are distributed throughout the mucosa
inserted in the auricle and 5 had the needle taped to the and submucosa of the gastrointestinal tract. The nerve
auricle but not inserted. Body weight and the levels of also transmits neurochemical signals (triggered by
several appetite-regulatory peptides were measured to gastrointestinal hormones) to the diencephalon and
examine treatment effects. Despite the small sample neocortex via the brainstem. Ghrelin is the only

4 Ito H, Yamada O, Kira Y, et al. BMJ Open Gastro 2015;2:e000013. doi:10.1136/bmjgast-2014-000013

Ito H, Yamada O, Kira Y, et al. BMJ Open Gastro 2015;2:e000013. doi:10.1136/bmjgast-2014-000013

Table 2 Haematology and blood biochemistry

WCC RBC Hb Ht MCV MCH MCHC Platelet AST ALT TP BUN HDL LDL FBS
Case Measurement time (/L) (104/L) (g/dL) (%) (fL) (pg) (%) (L) (IU/L) (IU/L) (g/dL) (mg/dL) (mg/dL) (mg/dL) (mg/dL)
Acupuncture group
A Before 4800 387 11.4 35.9 93 29.5 31.8 22.3 14 12 7.7 18.1 51 125 98
1 week 4200 406 11.8 36.7 90 29.1 32.2 19.7 19 28 7.8 14.8 49 112 99
B Before 5400 449 13.6 42.2 94 30.3 32.2 18 27 31 6.4 13.6 55 34 92
1 week 4800 441 13.2 41.3 94 29.9 32 17 23 28 6.6 14.3 61 36 93
C Before 5300 411 11.5 38.3 93 28 30 37.2 21 9 7.6 13.1 71 115 96
1 week 5400 427 11.9 38.7 91 27.9 30.7 35.3 20 10 7.7 11.9 68 118 96
D Before 3200 428 13.2 41.4 97 30.8 31.9 22 22 18 7.1 12.2 51 94 81
1 week 3600 425 13.2 41.1 97 31.1 32.1 20.6 20 16 7 11.2 55 94 84
E Before 8300 488 14.7 45 92 30.1 32.7 28.7 25 32 7.7 9.5 62 118 98
1 week 7700 489 14.7 45.2 92 30.1 32.5 27.4 26 41 7.5 8.7 52 120 104
Placebo group
F Before 4700 453 12.6 40.1 89 27.8 31.4 22.3 23 20 7.7 10.5 48 100 83
1 week 5600 469 13 41.5 88 27.7 31.3 20 18 15 7.8 11.5 55 107 85
G Before 5200 457 13.7 44.3 97 30 30.9 17.9 21 20 7.4 17.5 67 79 76
1 week 4400 458 13.7 44.2 97 29.9 31 16.9 19 21 7.6 12.8 71 75 80
H Before 5700 448 13.6 42 94 30.4 32.4 20.8 ND ND ND ND ND ND 89
1 week 5000 443 13.4 42.5 96 30.2 31.5 23.3 19 13 7.3 11 89 118 88
I Before 6600 436 8.8 31.7 73 20.2 27.8 46.4 13 15 7.6 13.1 46 146 90
1 week 6300 423 8.3 29.9 71 19.6 27.8 56 15 17 7.8 13.4 46 121 94
J Before 4500 455 13.9 41.6 91 30.5 33.4 18.5 17 12 7.3 13.9 43 130 ND
1 week 4900 433 13.6 40.2 93 31.4 33.8 19.3 15 13 7.1 11.7 45 124 88
ALT, alanine transaminase; AST, aspartate transaminase; BUN, Blood urea nitrogen; FBS, fasting blood sugar; Hb, haemoglobin; HDL, high-density lipoprotein; Ht, haematocrit; LDL,
low-density lipoprotein; MCH, mean corpuscular haemoglobin; MCHC, MCH concentration; MCV, mean corpuscular volume; ND, not done because of insufficient blood samples; RBC, red
blood cell; TP, total protein; WCC, white cell count.

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Table 3 Changes in feeding-related peptides

Insulin C-peptide ACTH Leptin Active ghrelin Desacyl-ghrelin Adiponectin
Case Measurement time (U/mL) (ng/mL) (pg/mL) (ng/mL) (fmol/mL) (fmol/mL) (g/mL)
Acupuncture group
A Before 5.9 1.1 13 13.2 4.65 83.8 8.57
1 week 5.1 1 12 9.8 3.36 40.4 7.33
B Before 2.8 1 22 8 15.3 172 5.08
1 week 5.4 1.4 18 8.7 17.1 174 5.15
C Before 3.6 1 13 5.9 20.7 206 7.64
1 week 6.8 1.4 21 6.3 24.9 164 6.59
D Before 9.5 2.5 27 11.2 3.36 77.2 4.2
1 week 10.6 2.2 25 10.6 3.42 46.6 4.51
E Before 3 1.2 42 11.5 27.9 ND 13.6
1 week 3.7 1.3 47 12 22.5 387 11.4
Placebo group
F Before 6.8 2.7 17 11.8 6.14 175 8.56
1 week 14.5 2.4 23 12.9 32.8 114 6.83
G Before 4.2 0.8 41 5.4 15.2 93 7.74
1 week 3.8 1.1 24 5 17.3 102 8.99
H Before ND ND 15 11.6 11.3 314 11.4
1 week 6.9 1.2 18 10.5 28.1 138 10.3
I Before 6.2 1.3 34 10.2 11 208 8.36
1 week 11.1 2 31 11.5 18 102 8.47
J Before 5.8 1.2 19 10.5 5.95 43.4 2.33
1 week 6.5 1.5 18 14.7 7.63 170 2.51
ACTH, adrenocorticotropic hormone; ND, not done because of insufficient blood samples.

appetite-inducing peptide produced peripherally;20 the pathways and through the blood.21 The concentration of
hormone is produced primarily by gastrointestinal endo- ghrelin in the blood rises during fasting and decreases
crine cells located within the gastric body and it plays an after eating. Ghrelin can pass through the bloodbrain
important role in energy metabolism by increasing appe- barrier and bind to ghrelin receptors in the arcuate
tite and regulating gastrointestinal functions. Ghrelin nucleus of the hypothalamus.22 However, ghrelin recep-
transmits information about hunger and growth tors are also expressed at the vagal afferent terminals,23
hormone levels to the nerve centre via afferent vagal and ghrelin excreted from the stomach transmits signals
to the nerve centre via these receptors, which increases
the appetite.24 Ghrelin is secreted when the stomach is
empty, which promotes gastric peristalsis. The hormone
then stimulates the brain via the circulation (it is present
in the blood) and via vagal afferent pathways. Electrical
signals are then transmitted to the stomach via vagal
efferent pathways, which again induce gastric peristalsis.
Hsu et al25 conducted a randomised controlled trial of
auricular acupuncture in 45 obese women. The acupunc-
ture sites were the same as those used in this study and the
results conrmed the biochemical effects of auricular acu-
puncture in humans. However, there was no clear differ-
ence between the acupuncture and placebo groups in
terms of body weight before and after treatment.
Furthermore, signicant decreases in leptin levels and sig-
nicant increases in ghrelin levels were observed in the
acupuncture group. These results are different from those
Figure 3 Percentage change in ghrelin levels at 1 week after reported in this study. This difference may be attributable
the start of acupuncture. Black columns denote the to the fact that we compared percentage changes in body
acupuncture group (AE) and grey columns denote the weight and ghrelin levels in each individual participant
placebo group (FJ). The percentage change in ghrelin levels
before as well as after treatment, whereas Hsu et al com-
was calculated as follows: ((value after stimulationvalue
pared the group values. Also, with regard to changes in
before stimulation)/value before stimulation)100 (%). No
member of the acupuncture group showed a significant body weight, Hsu et al compared values after 6 weeks and
increase in active ghrelin levels ( p=0.89). found no differences, whereas this study found that body

6 Ito H, Yamada O, Kira Y, et al. BMJ Open Gastro 2015;2:e000013. doi:10.1136/bmjgast-2014-000013

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Competing interests None. acupuncture stimulation on nonobese, healthy volunteer subjects.
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