Effects of Auricular Acupressure Combined with Low-Calorie Diet on the Leptin Hormone in Obese and Overweight Iranian Individuals

Abstract

Human leptin is a peptide hormone that is released from white adipocytes. The absence of leptin or its receptor leads to uncontrolled food intake, leading to obesity. In the present work, the effects of auricular acupressure combined with low-calorie diet on the leptin hormone level were investigated.
Volunteers (n=86) with body mass indices (BMI) between 25 and 45 kg/m(2) were randomised into a case (n=43) or a control (n=43) group. Participants in each group received a low-calorie diet for 6 weeks. The case group was treated with auricular acupressure and the control group received a sham procedure. Plasma leptin levels, body fat mass, body weight and BMI were measured before and after treatment.
Participants who received auricular acupressure showed significant reductions in their plasma leptin levels (18.57%, p<0.01) as well as in their body fat mass (4%, p<0.05). These changes were not observed in the control group. The reduction in leptin was significantly greater in the acupressure group than the controls.
Auricular acupressure combined with a low-calorie diet significantly reduced plasma levels of leptin. However, the mechanism of this reduction is not clear.

Full text

Original paper
Acupunct Med 2012;30:208–213. doi:10.1136/acupmed-2011-010121208
ABSTRACT
Background Human leptin is a peptide hormone
that is released from white adipocytes. The absence
of leptin or its receptor leads to uncontrolled food
intake, leading to obesity. In the present work, the
effects of auricular acupressure combined with
low-calorie diet on the leptin hormone level were
investigated.
Methods Volunteers (n=86) with body mass
indices (BMI) between 25 and 45 kg/m
2
were
randomised into a case (n=43) or a control (n=43)
group. Participants in each group received a
low-calorie diet for 6 weeks. The case group was
treated with auricular acupressure and the control
group received a sham procedure. Plasma leptin
levels, body fat mass, body weight and BMI were
measured before and after treatment.
Results Participants who received auricular
acupressure showed signifi cant reductions in their
plasma leptin levels (18.57%, p<0.01) as well as in
their body fat mass (4%, p<0.05). These changes
were not observed in the control group. The
reduction in leptin was signifi cantly greater in the
acupressure group than the controls.
Conclusions Auricular acupressure combined with
a low-calorie diet signifi cantly reduced plasma levels
of leptin. However, the mechanism of this reduction
is not clear.
INTRODUCTION
Human leptin is a 167-amino-acid peptide hor-
mone that is released from white adipocytes.
Serum leptin concentration appears to refl ect
total body fat mass.
1 2
Leptin can also be syn-
thesised by the brown adipose tissue, placenta,
ovaries, skeletal muscle, stomach, mammary
epithelial cells, bone marrow, pituitary and
liver.
3 4
Stimulation of leptin receptors in the
hypothalamic nuclei decreases fat storage and
inhibits appetite through several mechanisms.
2
5–8
The absence of leptin or its receptor leads to
uncontrolled food intake, leading to obesity.
Previous studies have shown that hyper-
phagia and obesity in mice or humans may
be the outcome of mutations in leptin recep-
tors or a consequence of inadequate leptin
secretion by fat cells.
9
However, circulating
levels of leptin do not decrease in people who
are obese. This may be because plasma levels
of leptin rise in proportion to the increased
body fat mass.
10 11
Therefore, obesity may be
associated with leptin resistance,
10 11
caused
by defects at the level of leptin receptors or
in post-receptor signalling pathways.
12
The
combination of the two mechanisms could
explain the obesity: fi rst, the absence of lep-
tin or its receptor leads to uncontrolled food
intake in normal people;
2 5–8
second, the leptin
resistance that is caused by defects in leptin
receptors or the large increase in leptin signals
in obese people.
10–12
However, obesity is now
recognised as a low-grade infl ammatory state
that affects iron metabolic pathways through
the iron regulatory peptide hepcidin.
13 14
Leptin, as a positive regulator of hepcidin,
may improve iron metabolism disorders in
obese individuals.
13 14
Also, mice with leptin
or leptin receptor defi ciencies are protected
against the development of several infl am-
matory and autoimmune diseases. Thus, lep-
tin appears to have a central role in immune
response.
15
Although many complementary
therapies have been proposed for the treat-
ment of obesity, few are truly therapeutic.
16
Currently, the most popular treatments for
obesity are diet, exercise, pharmacological
agents, surgery and acupuncture.
17 18
Many
overweight people are aware that diet can
help them lose weight, but have diffi culties
suppressing their appetite.
In recent decades, the use of acupuncture
has been growing.
18–25
It is claimed that acu-
puncture has useful long-term effects on
body weight (BW) and appetite control;
26 27
however, some fi ndings are in confl ict with
this claim.
28
Regardless, recent studies show
Effects of auricular acupressure combined with
low-calorie diet on the leptin hormone in obese
and overweight Iranian individuals
Mahsa Darbandi,
1
Sara Darbandi,
1
Majid Ghayor Mobarhan,
1,2
Ali Akbar Owji,
3
Baxiao Zhao,
4
Kambiz Iraji,
5
Hamid Abdi,
1
Mehdi Saberfi roozi,
6
Mohsen Nematy,
1,2
Mohammad Safarian,
1,2
Mohammad Reza Parizadeh,
1
Parisa Abbasi,
1
Masoud Salehmoghadam,
1
Majid Fardaei,
7
Mohammad Hossein Dabbaghmanesh,
8
Gordon Ferns,
9
Pooneh Mokarram
3,6
1
Department of Medicine,
Biochemistry and Nutrition
Research Center, Mashhad
University of Medical Sciences,
Mashhad, Iran
2
Cardiovascular Research
Center, Avicenna (Bu-Ali)
Research Institute, Mashhad
University of Medical Sciences,
Mashhad, Iran
3
Department of Biochemistry,
School of Medicine, Shiraz
University of Medical Sciences,
Shiraz, Iran
4
School of Acupuncture-
Moxibustion and Tuina, Beijing
University of Chinese Medicine,
Beijing, China
5
Department of Resource
Development and Management,
Shiraz University of Medical
Sciences, Iran
6
Gastroenterohepatology
Research Center, Nemazee
Hospital, School of Medicine,
Shiraz University of Medical
Sciences, Shiraz, Iran
7
Department of Genetics, Shiraz
University of Medical Sciences,
Shiraz, Iran
8
Endocrine Research Center,
Department of Internal
Medicine, Nemazee Hospital,
School of Medicine, Shiraz
University of Medical Sciences,
Shiraz, Iran
9
Institutes for Science and
Technology in Medicine, Keele
University, Hartshill, UK
Correspondence to
Pooneh Mokarram,
Department of Biochemistry,
School of Medicine and
Gastroenterohepatology
Research Center, Nemazee
Hospital School of Medicine,
Shiraz University of Medical
Sciences, 7134853185,
Shiraz, Iran;
mokaram2@gmail.com.
MD and SD contributed
equally to this work.
Accepted 11 May 2012
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Original paper
Acupunct Med 2012;30:208–213. doi:10.1136/acupmed-2011-010121 209
that exercise alone is not a good way to reduce weight
through decrease in leptin and body fat mass.
29 30
Many
studies have investigated the effects of acupuncture
on weight loss and appetite control,
27 31–33
but only one
study has reported the effects of auricular acupuncture
alone on plasma levels of leptin hormone, body fat
mass, body mass index (BMI) and BW in women.
24
Since
blood leptin levels regulate the immune responses
15
and affect iron metabolic pathways through hepcidin
expression,
13 14
leptin level regulation in obese people
may play an important role in healthcare. Here, we
examined the effects of combined auricular acupres-
sure and low-calorie diet treatment on the plasma lev-
els of leptin in overweight and obese people. If leptin
levels could be controlled by auricular acupressure and
low-calorie diet, it could be an alternative approach to
reduce the complications of obesity.
MATERIALS AND METHODS
Study design and subjects
A total of 90 overweight or obese individuals were
recruited from the nutrition clinic of Ghaem Hospital,
Mashhad, Iran. They had received no other weight
control treatments and had no medical or drug history
within 3 months before their participation in the study.
The participants were given verbal and printed infor-
mation about the objectives of the study, were given
time to discuss the study and were encouraged to ask
questions. Those participants with diabetes, severe
hypertension, heart disease, endocrine abnormalities,
hepatocellular diseases, or those who were pregnant or
refused to participate at any point, were excluded from
the study (n=10). In all, 90 participants were eventu-
ally enrolled (16 men and 74 women) with an age range
of 18–55 years and a BMI between 25 and 45 kg/m
2
.
All participants provided written informed consent, and
all forms were fi led in their medical records. The study
was approved by the Ethics Committee of Mashhad
University of Medical Sciences.
Anthropometric and biochemical assessments were
performed before and after treatment. Subjects were
enrolled in the study after checking for the inclu-
sion/exclusion criteria, and were arranged into pairs
matched by gender, age and BMI category. Using ran-
dom numbers generated in Microsoft Excel (Redmond,
Washington, USA), pairs were randomised into two
equal groups (n=45).
One group designed as the case group received auric-
ular acupressure with a low-calorie diet, and the other
(control) received sham auricular acupressure with the
same low-calorie diet. This report used the rounded BMI
values of 25 and 30 as boundary values, 30>BMI≥25 as
overweight and ≥30 as an index of obesity. The study
design is shown in fi gure 1.
The participants were asked to follow a washout diet
(isocaloric diet) for 2 weeks before starting the trial, and
then consumed a low-calorie diet for 6 weeks. The low-
calorie diet was observed on a 500 kcal energy defi cit per
day, below the individual’s daily energy requirements.
Resting energy expenditure was calculated with Harris
and Benedict’s equation,
34
and was used to determine
the amount of food per day for each participant. The
washout diet and the 6-week dietary programme for
each participant were planned by a nutritionist based
on the participant’s energy expenditure. The partici-
pant’s compliance was monitored every week.
Auricular acupressure treatment
Six standardised acupressure points were selected
on the external ear according to the usual tenets of
Chinese medicine and clinical experience: Shenmen
(TF4), Stomach (CO4), hunger point, Mouth (CO1),
centre of ear (HX1) and Sanjiao (CO17). Acupressure in
the case group was applied with routine ear press plas-
ters and seeds.
20
After sterilising the acupuncture points
with 75% alcohol preparation pads, the acupunctur-
ist applied the ear pressing plaster with the seed at
the acupuncture points. Ear pressing plasters (Vaccaria
ear seeds, Beijing Zhongyan Taihe Medicine, Beijing,
China) were applied to acupuncture points on both
ears in each treatment and were kept on the ear for 3
days.
20
All participants were requested to apply pres-
sure to the auricular points before eating. Fresh pressing
plasters were placed on the points twice a week for a
total of 6 weeks.
20
The procedure was performed by an
expert acupuncturist. No damage was observed in the
acupressure treated auricles and no short-term adverse
effects were reported.
Sham auricular acupressure in controls
The control group received sham auricular acupressure
using placebo ear plasters without seeds (Vaccaria ear
seeds). Hip (AH5), Spleen (CO13), Nose and Oesophagus
(CO2) points were used for sham acupressure. The treat-
ment procedure was the same as in the case group.
Anthropometric measurements
For all the patients, BW, BMI and body fat mass were
measured with a body composition analyser Tanita
BC-418 (Tanita, Tokyo, Japan) according to a standard
protocol.
35
The participants’ height was measured and
recorded with a standard procedure. These variables
were recorded at the beginning of the study and the
day after the treatment ended. BMI was used to classify
participants as overweight (25–29.9 kg/m
2
) or obese
(BMI≥30 kg/m
2
). All measurements were recorded with
a standard method between 7.00 and 8.00 am, after the
participants had abstained from food since the previous
evening.
Plasma samples
Blood samples were collected before and after treat-
ment. Plasma was prepared within 2 h after blood col-
lection and stored at −80°C until analysis. Haemolysed
samples were excluded.
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Original paper
Acupunct Med 2012;30:208–213. doi:10.1136/acupmed-2011-010121210
Leptin hormone measurement
Leptin concentration in the plasma was measured
in duplicate with a commercial sandwich ELISA kit
(Human Leptin ELISA, Clinical range, Biovendor,
Heidelberg, Germany).
36–38
Statistical analysis
All statistical analyses were performed with SPSS soft-
ware (V. 16, Chicago, Illinois, USA). The results are pre-
sented as mean±SD. Paired t tests were used to compare
related samples and independent t tests were used to
compare independent samples. In all cases, p<0.05 was
considered as statistically signifi cant.
RESULTS
In each group 43 participants completed the study and
two dropped out at the end of the study due to personal
reasons and long course of the treatment. There were
no signifi cant differences between the case and con-
trol groups when their mean values of age, sex, height,
weight and BMI were compared (table 1). Likewise,
body fat mass and plasma leptin levels did not dif-
fer signifi cantly between the case and control groups
before the treatment (p>0.05).
Volunteers in the case group showed signifi cant
reductions in their mean values of BW (3.4%, p<0.01)
and BMI (3%, p<0.01) after treatment with combined
low-calorie diet and auricular acupressure for 6 weeks.
Mean values of BW (1.7%, p<0.01) and BMI (2%,
p<0.01) also decreased signifi cantly after 6 weeks of
sham treatment. Although the percentage of weight
loss in the case group was twice as great as in the con-
trol group, the difference was not statistically signifi -
cant. Likewise, the total body fat mass did not differ
signifi cantly between the two groups.
Data in table 2 shows statistically signifi cant reduc-
tions in the body fat mass and plasma levels of leptin
Figure 1 Flowchart related to the study design of this work.
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Original paper
Acupunct Med 2012;30:208–213. doi:10.1136/acupmed-2011-010121 211
in the participants treated with auricular acupressure
for 6 weeks. The control group showed no signifi cant
changes in these variables after 6 weeks of sham treat-
ment. There was a signifi cant difference in plasma lev-
els of leptin between the groups.
As summarised in table 3, a highly signifi cant (p<0.01)
positive correlation was observed between plasma lev-
els of leptin and the obesity indices after the real and
sham treatments used in this study.
DISCUSSION
Acupuncture has been found effective in weight loss
and suppression of appetite in some studies
39 40
though
not in all.
24
Secretion of leptin may be an important
means by which the adipose tissue signals the brain that
enough energy has been stored and intake of food is no
longer necessary.
2
Thus, interfering with the leptin sys-
tem is one of the possible mechanisms by which auric-
ular acupuncture controls appetite and induces weight
loss.
39
However circulating concentrations of leptin are
elevated in obese people and rodents.
41
The high levels
of leptin may result in leptin resistance which appears
to be a major factor in obesity.
10–12
The main fi nding of
this study is that acupressure reduced plasma levels of
leptin in overweight and obese participants. Although
Hsu et al studied the effects of auricular acupuncture on
obese women, we included both genders. Also, they
used auricular acupuncture alone as a main treatment
24
but volunteers in our study were subjected to auricular
acupuncture and a low-calorie diet. In another method
of acupuncture Kang et al employed body electroacu-
puncture and ear point tapping and pressing treatment
for subjects in the case group.
39
This method of treat-
ment also showed to be effective in reducing serum
leptin levels and BW.
Another fi nding of our study was that acupressure
caused a decline in total body fat mass of subjects in
the case group. This decrease is in line with our results
regarding the decreased levels of plasma leptin in the
case group. Notably, adipose tissue is the major source
of circulating leptin; therefore, lowering effects of acu-
pressure on plasma leptin may be due to a decrease in
the body fat mass. This notion is also supported by
the positive correlation we observed between plasma
levels of leptin and body fat mass. However, the exact
mechanism of the reducing effects of acupressure on the
plasma leptin remains to be elucidated. Further research
will also be needed to understand the mechanism by
which auricular acupressure affects body fat mass.
Blood leptin levels regulate the immune responses
15
and affect iron metabolic pathways through hepcidin
expression.
13 14
Indeed, hepcidin may play an important
role in hypoferremia of infl ammation in obese people.
The expression of hepcidin is regulated by iron homeo-
stasis, hypoxia, infl ammation and leptin. Thus, obesity
Table 1 Demographic data of case and control groups
Group Sex Number Age, years Height, m BW, kg BMI, kg/m
2
Case Women 37 37.62±9.49 1.58±0.06 81.20±11.64 32.23±3.92
Men 6 37.00±7.61 1.69±0.06 88.95±9.44 30.80±1.40
Total 43 37.57±9.26 1.59±0.06 81.89±11.58 32.11±3.78
Control Women 37 37.54±9.83 1.58±0.05 79.13±9.64 31.85±3.97
Men 6 38.40±9.83 1.67±0.07 90.44±6.26 32.60±1.41
Total 43 37.65±9.71 1.59±0.06 80.50±9.96 31.94±3.75
Values are expressed as mean ±SD. Independent t tests were used to compare case and control groups and no
signifi cant differences were observed (p>0.05).
BMI, body mass index; BW, body weight.
Table 2 Effects of auricular acupressure on obesity indicators in overweight and obese participants
Variable
Case group Control group
Comparison of the
changes between
case and control
groups (p value)Pretreatment Post-treatment
Within-group
comparison
(p value) Pretreatment Post-treatment
Within-group
comparison
(p value)
Body weight, kg 81.89±11.58 79.09±11.84 0.001 80.50±9.96 79.08±10.51 0.001 0.1
BMI, kg/m
2
32.11±3.78 31.12±3.73 0.001 31.94±3.75 31.28±3.90 0.001 0.6
Body fat mass, kg 31.21±7.90 29.90±7.74 0.01 30.63±7.00 30.02±7.40 0.2 0.2
Plasma leptin level, mg/m
3
0.26.±0.14 0.21±0.13 0.001 0.23±0.12 0.22±0.13 0.4 0.007
Values are expressed as mean±SD. Paired t tests were used to compare variables before and independent t tests were used to compare the changes in values
between case and control groups. No signifi cant differences were observed between case and control groups at baseline (p>0.05).
BMI, body mass index.
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Original paper
Acupunct Med 2012;30:208–213. doi:10.1136/acupmed-2011-010121212
treatment with combined treatment in obese people
may have an important role in reduction of hepcidin
and hypoferremia compensation through leptin decline.
Therefore, in our study, we just evaluated the level of
leptin after combined treatment and our interest has
now shifted to the identifi cation of hepcidin and iron
metabolism changes in future studies.
Although participants in the case group showed a
reduction in mean values of their BW and BMI after 6
weeks of treatment, but the difference between these
mean values and those of subjects in the control group
did not achieve signifi cance. These fi ndings are not con-
sistent with those of other investigators who found
signifi cant changes in BW after acupuncture.
24 28
The
discrepancy may be in part because of the differences
in demographic and anthropometric characteristics
of the participants and in the duration of treatment. It
would be of interest to test other auricular acupressure
points in the future studies. We also recommend that
similar studies be conducted in a metabolic clinic setting
to better control other variables such as dietary intake
(matched across case and control participants), and to
include a third group that receives only diet treatments.
Conclusions
In participants who received a combination of low-cal-
orie diet and auricular acupressure, plasma leptin lev-
els decreased more than in participants who received
sham auricular acupressure. Our results are consistent
with the notion that auricular acupressure combined
with dietary modifi cation is a benefi cial complemen-
tary treatment for reducing body fat mass. However,
these fi ndings should be reconfi rmed by other studies
with larger sample sizes and with a third group treated
with a low-caloric diet alone.
Acknowledgements This project was supported by Mashhad University of Medical
Sciences, Beijing University of Chinese Medicine, the Ministry of Health and Medical
Education of Iran and Shiraz University of Medical Sciences. The authors thank the staff
of the Research Institute of Nemazee Hospital in Shiraz and the Nutritional Clinic of
Mashhad Ghaem Hospital for their assistance and K Shashok (AuthorAID in the Eastern
Mediterranean) for improving the use of English in the manuscript.
Contributors AAO, BZ, GF, MS, MGM, PM, SD, MD: designed and coordinated the
study and wrote the manuscript. MGM, MN, MS: dietician and food advice. SD, MD,
HA, PA: recruitment of subjects and collection of data. SD, MD, PM: carried out sta-
tistical analysis and the main writing process of the manuscript; were also responsible
for the performance of the biochemistry laboratory resistance test analysis, and were
involved in clinical and laboratory data collection. BZ, HA: acupuncturists. MRP, MHD,
MS, MGM: took part at their respective clinical centres and were involved in interpreta-
tion of the data; also participated in the review of the fi nal manuscript.
Competing interests None.
Patient consent Obtained.
Ethics approval The study was approved by the Ethics Committee of Mashhad
University of Medical Sciences.
Provenance and peer review Not commissioned; externally peer reviewed.
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Table 3 Correlation between the changes in plasma
leptin concentrations and obesity indices after auricular
acupressure
Changes Leptin hormone levels
Case Control Case and control
Body fat mass r 0.466 0.175 0.345
p V
alue
0.003 0.234 0.002
Body weight r 0.576 0.493 0.573
p Value 0.001 0.001 0.001
Body mass indices r 0.573 0.565 0.596
p Value 0.001 0.001 0.001
p<0.05 was considered signifi cant, p<0.01 was considered highly
signifi cant.
r, Pearson’s correlation coeffi cient.
Summary points
Acupressure is sometimes used to assist weight loss.
▶
A 6 week course of acupressure reduced leptin levels signifi cantly
▶
compared with sham acupressure.
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acupmed-2011-010121.indd 213acupmed-2011-010121.indd 213 8/24/2012 5:05:39 AM8/24/2012 5:05:39 AM
group.bmj.com on December 30, 2012 - Published by aim.bmj.comDownloaded from

doi: 10.1136/acupmed-2011-010121
2012
2012 30: 208-213 originally published online June 22,Acupunct Med
Mahsa Darbandi, Sara Darbandi, Majid Ghayor Mobarhan, et al.
in obese and overweight Iranian individuals
with low-calorie diet on the leptin hormone
Effects of auricular acupressure combined
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