Hindawi Evidence-Based Complementary and Alternative Medicine Volume 2017, Article ID 3080547, 16 pages https://doi.org/10.1155/2017/3080547 Review Article The Effect of Auricular Acupoint Stimulation in Overweight and Obese Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials Tzu-LinYeh,1Hsin-HaoChen,1Tsung-PingPai,2Shu-JungLiu,3 Shang-LiangWu,4Fang-JuSun,5andLee-ChingHwang2 1DepartmentofFamilyMedicine,HsinchuMacKayMemorialHospital,No.690,Section2,GuangfuRoad,EastDistrict, HsinchuCity,Taiwan 2DepartmentofFamilyMedicine,TaipeiMacKayMemorialHospital,No.92,Section2,ZhongshanNorthRoad, TaipeiCity,Taiwan 3DepartmentofMedicalLibrary,MacKayMemorialHospital,TamsuiBranch,No.45,MinshengRoad,TamsuiDistrict, NewTaipeiCity,Taiwan 4SchoolofMedicine,GriffithUniversity,GoldCoastCampus,ParklandsDr.,Southport,QLD4215,Australia 5DepartmentofMedicalResearch,MacKayMemorialHospital,No.92,Section2,ZhongshanNorthRoad,TaipeiCity,Taiwan CorrespondenceshouldbeaddressedtoLee-ChingHwang;hlc@mmh.org.tw Received 12 June 2017; Revised 11 August 2017; Accepted 22 August 2017; Published 5 December 2017 AcademicEditor:KieranCooley Copyright©2017Tzu-LinYehetal.ThisisanopenaccessarticledistributedundertheCreativeCommonsAttributionLicense, whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited. Objective. To investigate the effect of auricular acupoint stimulation on overweight and obese adults. Methods. We searched databasesincludingPubMed,EMBASE,AlliedandComplementaryMedicineDatabase,NationalKnowledgeInfrastructure,and thePerioPathIndextoTaiwanPeriodicalLiterature.ThemodifiedJadadscalewasusedtoassessstudyquality.Weinvestigatedthe effectofauricularacupointstimulationonanthropometricmeasurements.Results.Eighteenrandomizedcontrolledtrials(RCTs) wereincludedinoursystematicreview.ThirteenRCTswerepooledinameta-analysisthatrevealedasignificantreductioninbody weight(BW)withameandifference(MD)of−1.21kganda95%confidenceinterval(CI)from−1.94to−0.47withaheterogeneity of𝐼2 =88%.Significantdecreasesinbodymassindex(BMI;MD:−0.57kg/m2;95%CI−0.82to−0.33;𝐼2 =78%),bodyfat(BF; MD:−0.83%;95%CI−1.43to−0.24;𝐼2 =0%),andwaistcircumference(WC;MD:−1.75cm;95%CI−2.95to−0.55;𝐼2 =87%) werealsorevealed.Conclusions.Thismeta-analysisshowsthatauricularacupointstimulationimprovesphysicalanthropometric parametersincludingBW,BMI,BF,andWCinoverweightandobeseadults.Thesemethodsarelesseffectiveonhipcircumference andwaist-to-hipratio. 1.Introduction anthropometricmeasurementsforevaluatingoverweightand obesepatientsarebodyheight,bodyweight(BW),bodymass Obesity is an increasingly common chronic disease world- index (BMI), body fat (BF), waist circumference (WC), hip wide. Overweight and obesity represent a rapidly growing circumference(HC),andwaist-to-hipratio(WHR).Anthro- threat to the health in an increasing number of countries pometric measurements are reliable physical parameters to [1].TheprevalenceofadultobesityintheUnitedStateswas evaluatetheeffectsofweightloss. 34.9% based on data collected by the National Health and Weight loss provides a number of cardiac [6, 7] and Nutrition Examination Survey between 2011 and 2012 [2]. noncardiac benefits [8], and a number of complementary Obesity and increased central fat increase the relative risk therapiesareusedtotreatoverweightandobeseindividuals. ofhypertension,hypercholesterolemia,anddiabetesmellitus Auricular acupoint stimulation, also called ear stimulation [3] and increase morbidity and mortality [4, 5]. The basic or auriculotherapy, is a method of diagnosing and treating 2 Evidence-BasedComplementaryandAlternativeMedicine physical and psychosomatic dysfunctions by stimulating a medication, or other traditional Chinese medicine in the specific point in the ear. Many methods are used, such interventionorcontrolarm. asfingeracupressure,electricalstimulation,lasers,different AuthorsTzu-LinYehandHsin-HaoChenindependently types of needles, seeds, and magnetic balls [9]. Of these, used the modified Jadad scale to assess the methodolog- auricularacupuncturebyneedleisthemostcommon.Auric- ical quality of each included study. The modified Jadad ularacupunctureisaconvenientmethodusedtotreatmany scaleincludeseightitemstoevaluaterandomization,blind- conditions, such as substance abuse, pain, obesity, anxiety, ing,withdrawals,dropouts,inclusionandexclusioncriteria, epilepsy,andsleepdisorders.Bothexperimentalandclinical adverse reactions, and statistical analysis [15]. The score of datasuggestthatauricularacupuncturehasbeneficialeffects eachstudyrangesfromzero(thelowestquality)toeight(the incombattingthemechanismsofobesity[10],butthereare highestquality).Studieswereclassifiedasgoodtoexcellent only a limited number of evidence-based trials [11]. Recent (highquality)iftheyhadascoreoffourormore.Thedetailed systematic reviews and meta-analyses concerning obesity scores of each study are summarized in Appendix S3. If have focused on body acupuncture [12], acupoint catgut the two authors had different opinions when assessing and embedding [13], and pharmacoacupuncture [14]. There has selecting the studies to include, agreement was reached by beenlittlecomprehensiveinformationpublishedfocusingon consensus with the third author, Tsung-Ping Pai. The study auricular acupoint stimulation in the treatment of obesity. flowdiagramisshowninFigure1. The aim of this study is to perform an updated systematic review and meta-analysis to evaluate the effect of auricular 2.3. Data Extraction and Analysis. Tzu-Lin Yeh and Tsung- acupoint stimulation, including auricular acupuncture and PingPaiindependentlyextractedthedatafromallincluded auricularacupressure,onoverweightandobeseadultsusing studies, and the following data were collected: first author’s anthropometricmeasurements. name, year of publication, study size, population characteristics, mean age, sex ratio, type of acupuncture, acupoint 2.Methods selection, treatment frequency, treatment duration, control groupmethod,clinicaloutcomemeasurements,andadverse Thissystematicreviewandmeta-analysiswereconductedin effects(Table1). accordancewiththePRISMA-Pguidelines(AppendixS1). Data were analyzed using the mean difference (MD) with95%confidenceintervals(CI)forcontinuousoutcomes. 2.1. Data Sources and Search Strategy. We searched the RevManversion5.3software(CochraneCollaboration)was following databases from inception to April 2017: PubMed, usedforalldataanalyses.Themeta-analysiswasconducted EMBASE, Allied and Complementary Medicine Database whenthetrialshadacceptableclinicalhomogeneityandsta- (AMED),ChinaNationalKnowledgeInfrastructure(CNKI), tisticalheterogeneity.Arandomeffectmodelwasemployed and the PerioPath Index to Taiwan Periodical Literature. usingDerSimonianandLaird’smethodduetothesignificant We used the keywords: “((Acupuncture, Ear) OR (auricu- heterogeneityexpectedamongthestudies[16].Heterogeneity lar acupuncture) OR (auricular acupressure) OR (auricular was quantified using the Cochran 𝑄 test and 𝐼2 statistics acupointstimulation)OR(auriculartherapy)OR(moxibus- [17,18],andsubgroupanalyseswereperformedfordifferent tion))AND((weightreduction)OR(overweight)OR(obe- study settings. Metaregression was also performed using sity)).”Ofthese,“Acupuncture,Ear”and“obesity”areMed- Comprehensive Meta-Analysis ver. 3 software (Biostat Inc., icalSubjectHeadingsTerms.Wedidnotlimitthelanguage, Englewood, NJ, USA) to explore the possible sources of year,orarticletypetoenableacomprehensiveandthorough heterogeneity.Potentialpublicationbiaswasanalyzedwitha search. We also did not restrict the search to humans or funnelplotandEgger’stest[19]. adults. Tzu-Lin Yeh and Shu-Jung Liu each conducted the searchindependently.Disagreementswereresolvedthrough 3.Results discussionwiththethirdauthor,Tsung-PingPai.Thesearch strategyemployedisavailableinAppendixS2. 3.1.StudyCharacteristics. Figure1illustratesthesearchpro- cess and outcomes. A total of 18 RCTs were included for 2.2. Study Selection and Methodological Quality Assessment. systematicreview[20–37].Weassessedtheirqualityusingthe We included all publications fitting the purposes of our modified Jadad scale. Characteristics of the included trials study that followed our inclusion eligibility criteria: (1) and total modified Jadad scores are shown in Table 1. Two randomizedcontrolledtrials(RCTs)focusedonoverweight RCTs [24, 25] had the same study population group, and and obese human adults; (2) no effective treatment in the the duplicated population was excluded when we reported controlarmbesideslifestylemodification;(3)theacupoints theoverallpopulationsize.Weincludedbotharticlesinour in the intervention group that were restricted to the ears; meta-analysisbecausetheyhaddifferentoutcomemeasure- and (4) outcome measurements that include at least one mentsanddidnotinterferewithourstatistics. anthropometric measurement, either as a primary or as All of the RCTs were published between 1995 and 2016. secondary outcome of the paper. We excluded articles that A total of 1775 participants were included, with a female to were (1) irrelevant to the topic or target population; (2) maleratioof3:1,andameanageof38.9yearsold.Sixstudies duplicatepublications;(3)trialsofacross-overstudy;or(4) were conducted in Taiwan [23–25, 28, 31, 36], three studies confoundedbyotherfactorslikeeffectivebodyacupuncture, eachinChina[26,30,37]andIran[27,29,32],twostudies Evidence-BasedComplementaryandAlternativeMedicine 3 Records identified through database searching on PubMed (808), EMBASE (434), CNKI (374), AMED (34) ati fic PerioPath Index to Taiwan Periodical Literature (27) nti e d I Records identified (n = 1677) Duplicated records excluded (n = 150) ng Records after duplicates removed eni (n = 1527) e cr S Excluded by title and abstract (n = 1449) Articles excluded (n = 60) Full-text articles assessed for gibility eligibility (n = 78) ((ii)i) N Dout pRliCcaTt e(dn p=o 3p8u)lation (n = 2) Eli (iii) Not appropriate controlled arm (n = 8) (iv) Population: nontarget population (n = 8) Studies included in qualitative synthesis (n = 18) (v) Intervention rather than auricular point (n = 4) d e ud Articles excluded due to low quality (n = 5) Incl Studies included in (i) Insufficient data (n = 2) meta-analysis (n = 13) (ii) Modified Jadad scale <4 (n = 3) Figure1:Flowchartofthetrialselectionprocess. inSouthKorea[33,35],andoneRCTintheUSA[20],Egypt withoutseeds[27,29],orelectricstimulationwithnopower [21],Australia[22],andAustria[34]. supply[34].Onestudyusedsuperficialneedlingofthesame points used in the treatment arm by removing the needles 3.2. Intervention. The intervention methods varied among immediatelyafterinsertion[35]. the studies included. One trial in 1998 used an AcuSlim acupuncturedevice with electricalstimulationto the auric- 3.4. Outcome Measures. Every RCT enrolled in this study ularacupoint[22].SixRCTs [21,23,26,31,34,35,37]used included anthropometric measurements. In addition, seven traditionalauricularacupuncturewithstainlesssteelneedles, trials [23, 24, 26, 27, 31, 36, 37] investigated biochemical andtwoofthesealsousedelectricalstimulation[21,34].Most characteristics and five studies [23, 26, 29, 31, 36] evalu- oftheincludedarticlesperformedauricularacupressurewith atedobesity-relatedhormonepeptides.Psychologicalfactors other devices such as Sinapis alba seeds [33], metal beads wereevaluatedusingself-administeredquestionnairesintwo [31], Vaccaria seeds [25, 27–30, 32, 36, 37], an Acu-Stop studies [31, 33]. One publication [22] investigated appetite 2000device[20],oraJapaneseMagneticPearl[25].Oneof changes. Our objective was to ascertain the effect of auric- these RCTs also used electrical stimulation [36]. One trial ularacupointstimulationonanthropometricmeasurements, [24] compared two different auricular acupressure devices specifically. (JapaneseMagneticPearlandVaccariaseeds)withaplacebo. The number of auricular acupoints varied from one to six, 3.5. Results of Meta-Analysis. Two studies [34, 36] did not withanaverageof3.9.Themostcommonlyusedacupoints havesufficientdatatoperformameta-analysis.Wecontacted wereShenMen(TF4)andStomach(CO4).Treatmentlength theauthors,buttherewasnorawdataavailable.Threearticles rangedfrom3to12weeks,withanaverageof6.9weeks. hadarelativelylowJadadscoreof3andthuswereexcluded fromourmeta-analysis[21,26,37].Eventually,thirteenRCTs 3.3.Controls. Variousshamacupuncturemethodswereused thatachievedamodifiedJadadscoregreaterthanorequalto inthecontrolarmsofourincludedstudies.Nointervention four were included in our meta-analysis. The meta-analysis wasmentionedintwotrials[30,33].Onestudyin1995[20] resultsareshowninTable2. andonetrialin1998[22]usedirrelevantacupuncturepoints Overall,themeta-analysisshowedasignificantreduction in the wrist and thumb. Four articles used nonacupoints inBW,withanMDof−1.21kg,a95%CIof−1.94to−0.47, [21, 26, 36, 37]. Several studies used placebo needles or 𝑃=0.001,and𝐼2=88%(forestplotsareshowninFigure2). pseudo-interventions, including surgical tape [24, 25, 28], The meta-analysis also showed a significant reduction in needles without needle points [23, 31], acupressure devices BMI (MD: −0.57kg/m2; 95% CI: −0.82 to −0.33; 𝐼2 = 78%; 4 Evidence-BasedComplementaryandAlternativeMedicine d Adverseeffect 3bleedingearsintreatmentgroup NR NR 1mildinflamma-tion;9miltendernesscases NR M e C Mainoutcome (1)BW,BF,BF(2)BP(3)Complianc BW ∗(1)BW(2)Appetite∗change (1)BW,BMI,WC,HC(2)FBG,TG,TCH,HDL-C,LDL-C(3)Insulin,leptin,adiponectin,ghrelin,HOMA-IR (1)BMI(2)TCH,TG,HDL-C,LDL- requency/treatmentcourse Every2wks/12wks Everyday/3wks Twicedaily/4wks Twiceawk/6wks NR/8wks F studies. ControlgrouptreatmentSubjectsreceivedwristacupressuredeviceindominantsidemassaged,4timesaday StainlessneedleAAwithEStoshamAPonearESduration=25mins ESwithAcuSlimdevicetothumb(withoutAP)ESduration=15–20mins ShamAAusingplaceboneedles(withoutneedlepoint)AP:CO4,CO18,HG,TF4 Acupressuretape0.5∗0.5(cm)onear d oftheinclude Interventiongrouptreatment AAdevice(Acu-Stop2000)ondominantear,massaged,4timesaday StainlessneedleAAwithEStoAP1orAP2.ESduration=25minsAP1:CO4AP2:HGESwithAcuSlimdevicetoAPESduration=15–20minsAP:CO4,TF4Stainlesssteelneedle(0.2cmneedlepoint)toAP;noapplyanypressuretoAPAP:CO4,CO18,HG,TF4AuricularacupressuretoJapaneseMagneticPearlorVaccariaseeds s c e1:Characteristi Characteristicsofparticipants(gender,age) 16M/80F41.1 0M/30F21–35 NR>18 0M/45F±39.512.0 8M/76F18–20 l b a T e amplsize 96 30 60 45 84 S e dr difiedsco 5 3 7 7.5 4 oa Md a J Population Obeseadults Obesefemaleadults Overweightadults Obesefemaleadults Overweightadolescents Country USA Egypt Australia Taiwan Taiwan Study(year) Allisonetal.(1995)[20] Shafshak(1995)[21] RichardsandMarley(1998)[22] Hsuetal.(2009)[23] Hsieh(2010)[24] Evidence-BasedComplementaryandAlternativeMedicine 5 e s r e e s v Advereffect NR NR Noadeffect Mainoutcome (1)BW,BMI,BF(2)TCH,TG(3)FINS,HOMA-IR BW,WC ∗∗(1)BW,BMI,∗∗BF,WC,∗HC,WHR(2)FBG,TCH,TG,HDL-C,LDL-C,hs-CRP(3)∗7Anti-HSP2,∗0Anti-HSP6,∗5Anti-HSP6,∗0anti-HSP7 ment 2wks wks Frequency/treatcourse Everytwodays/1 NR/8wks Twiceawk/12 Controlgrouptreatment NeedleAAonshamAPonthebody AdhesivetapetoAPAP:CO1,CO4,CO6,CO18,TF4 EarpressingplasterwithoutseedtoshamAPAP:AH5,CO2,CO13 Continued. InterventiongrouptreatmentVaccariaseedstoAP;appliedpressuretoeachAPfor30–50timesbeforeeatingAP:CO4,CO17,CO18,TF4AcupressurewithJapaneseMagneticPearlonAPAP:CO1,CO4,CO6,CO18,TF4EarpressingplasterwithseedtoAPApplypressuretoAPbeforeeatingfor20secAP:CO1,CO4,CO17,HG,HX1,TF4 1: Table aracteristicsparticipantsender,age) NR18–65 5M/50F18–20 NR38 Chof(g e amplsize 200 55 169 S e dr difiedsco 3 4 4 oa Md a J opulation verweightadults Youngdultswithbdominalobesity verweightadults P O aa O Country China Taiwan Iran ) Study(year Hsiehetal.(2011)[26] Hsiehetal.(2011)[25] Abdietal.(2012)[27] 6 Evidence-BasedComplementaryandAlternativeMedicine e of e ers ntssA Adverseffect NR Noadveffect NR 1accoudizzineafterA Mainoutcome BW,BMI,BF (1)BW,BMI,BFM∗(2)Leptin BW,BMI,WC (1)BW,BMI,WC,HC,WHR(2)FBG,TG,TCH,HDL-C,LDL-C(3)Adiponectin,insulin,ghrelin,Leptin,HOMA-IR(4)WHOBREFlife-qualityscores nt quency/treatmecourse wiceawk/8wks wiceawk/6wks Everythreedays/4wks Threetimesawk/4wks e T T r F Controlgrouptreatment SurgicaltapetoAP.APpointswerenotpressedAP:CO4,CO18,HG,TF4 EarplasterwithoutseedstoAPAP:AH5,CO2,CO13,Nose NoAA ShamAAtoAPwithauricularneedlewithtipsremoved(needlewithoutneedlepoints)AP:CO4,CO18,HG,TF4 Continued. InterventiongrouptreatmentVaccariaseedstoAP.ApplypressuretoAPbeforeeatingEachAPfor1minAP:CO4,CO18,HG,TF4VaccariaseedstoAP.ApplypressuretoAPbeforeeatingAP:CO1,CO4,CO17,HG,HX1,TF4VaccariaseedstoAP.Applypressureoneachseedfor30secs/dayAP:CO4,CO7,CO13,CO18,HG,TF4 Applystainlessneedleswitha0.2cmtipormagneticmetalbeadstoAPAP:CO4,CO18,HG,TF4 1: Table Characteristicsofparticipants(gender,age) 33M/39F47.8 12M/74F±37.79.5 0M/60F34 0M/71F±40.711.3 e amplsize 72 86 60 71 S e dr difiedsco 7.5 6 4.5 7.5 oa Md a J n hte- ht opulatio verweighizophrniapatients verweigadults Obesefemaleadults Obesefemaleadults P Oc O s Country Taiwan Iran China Taiwan Study(year) Chingetal.(2012)[28] Darbandietal.(2012)[29] Heetal.(2012)[30] Lienetal.(2012)[31] Evidence-BasedComplementaryandAlternativeMedicine 7 e s r e e s v Advereffect Noadeffect NR NR NR Mainoutcome BW,BMI,BFM,HC ∗∗(1)BW,BMI,BF,WHR(2)Self-efficacy∗scale ∗∗BW,BMI,BF ∗∗(1)BW,BMI,∗∗WC,BFM,BF(2)BP nt atme 6wks wks wks wks cy/treourse awk/ kly/4 kly/6 kly/8 quenc wice Wee Wee Wee e T r F Controlgrouptreatment ShamAAwithplasterstoAPonbothearsfor3days.ApplypressuretoAPbeforeeatingAP:CO2,CO13,AH5 NOAA (cid:2)P-Stimdummy(nopowersupply)AP:CO4,CO7,HGShamAA,removedimmediatelyafterinsertion;AP:CO1,CO4,CO6,CO18,HX1 Continued. InterventiongrouptreatmentVaccariaseedstoAPonbothearsfor3days.ApplypressuretoAPbeforeeatingAP:CO1,CO4,CO17,HG,HX1,TF4ThreeSinapisalbaseedstoeachAP.ApplypressuretoAPfor5secs∗10times/point,threecourses/dayAP:CO1,CO4,CO6,TF4 ESwithaP-StimdeviceAP:CO4,CO7,HG AcupunctureneedleonAP1orAP2AP1:CO1,CO4,CO6,CO18,HX1;AP2:HG 1: Table Characteristicsofparticipants(gender,age) 40M38.5 0M/49F±20.71.1 0M/42F 6M/52F±38.611.8 e amplsize 40 49 42 58 S e dr difiedsco 7.5 5 7 6.5 oa Md a J Population Obesemaleadults Obesefemaleyoungadults Obesefemaleindividuals Overweightadults a a Country Iran uthKore Austria uthKore o o S S Study(year) Darbandietal.(2014)[32] Kimetal.(2014)[33] Schukroetal.(2014)[34] Yeoetal.(2014)[35] 8 Evidence-BasedComplementaryandAlternativeMedicine Table1:Continued. ControlInterventionCharacteristicsFrequency/treatmentAdverseModifiedSampleMainoutcomegroupgroupofparticipantsPopulationcourseeffectJadadscoresizetreatmenttreatment(gender,age)EStoAPandEStoshamthenapplyAP.ApplypressuretopressuretoeachAPwith(1)BMIeachAPwithVaccaria(2)BP,TCH,TGVaccaria35M/35FObeseNRWeekly/10wksseedsfor7.570±(3)Adiponectin,seedsfor31.38.8adults∗1min4∗leptin1min4times/daytimes/dayAP:CO4,AP:AH3,CO18,HG,SF3,SF4,SF6TF4VaccariaseedstoAP(1)BW,BMI,BFoneachearNeedleAAto(2)TCH,TGalternatingOverweight73M/47FNREvery2days/12wksshamAPon3120±(3)FINS,every2daysadults38.710.0bodyHOMA-IRAP:CO17,CO18,HG,TF4∗<0.05±𝑃betweentreatmentandcontrolgroups;AA:auricularacupuncture;anti-HSP:anti-heatshockprotein;AP:auricularacupoint;BF:bodyfatstandarddeviation.MI:bodymassindex;BP:bloodpressure;BW:bodyweight;ES:electricalstimulation;F:female;FBG:fastingbloodglucose;FINS:fastinginsulin;HC:hipcircumference;HDL-erol;HOMA-IR:homeostasismodelassessmentforinsulinresistance;HR:heartrate;hs-CRP:high-sensitivityC-reactiveprotein;LDL-C:low-densitylipoproteincholesterol;ported;sec:second;TCH:totalcholesterol;TG:triglycerides;WC:waistcircumference;WHR:waist-to-hipratio;wk:week;acupoints:ankle(AH3),hip(AH5),mouth(CO1),smallintestine(CO6),largeintestine(CO7),spleen(CO13),SanJiao(CO17),endocrine(CO18),hungerpoint(HG),centerofear(HX1),elbow(SF3),shoulder(SF4),clavicle Country Taiwan China essedasthemeanM:bodyfatmass;Blipoproteincholestminutes;NR:notre2),stomach(CO4),n(TF4). Study(year) Yehetal.(2015)[36] Hsu(2016)[37] Valuesareexprpercentage;BFC:high-densityM:male;min:esophagus(CO(SF6),ShenMe Evidence-BasedComplementaryandAlternativeMedicine 9 2𝐼 88%95%59%78%92%52%0%87%0%83%94%0%91%0%0%0% P0.0010.010.01<0.0010.03<0.0010.0060.0040.010.0090.170.520.010.150.150.81 o. ati r p hi o- CI)−0.47)−0.33)−0.22)−0.33)−0.04)−0.34)−0.24)−0.55)−0.10)−0.54)0.79)1.87)−0.78)0.00)0.00)0.07) HR:waist-t cmeasurements. MD(95%−−1.21(1.94,−−1.58(2.82,−−0.92(1.63,−−0.57(0.82,−−0.48(0.92,−−0.65(0.95,−−0.83(1.43,−−1.75(2.95,−−0.51(0.92,−−2.19(3.83,−−1.89(4.57,−0.46(.0.94,−−3.41(6.03,−−0.01(0.02,−−0.01(0.02,−−0.01(0.08, circumference;W metri waist o C: p W o hr e; ationonant articipants8301656657181655533636081654433489225636747320 meandifferenc mul P D: pointsti erence;M cu mf a u ctofauricular 𝑁Studies,1349124851046523514 val;HC:hipcirc effe nter The cei n 2: de Table nterventionuricularstimulationeeks’treatmenteeks’treatmenturicularstimulationeeks’treatmenteeks’treatmenturicularstimulationuricularstimulationeeks’treatmenteeks’treatmenturicularstimulationeeks’treatmenteeks’treatmenturicularstimulationeeks’treatmenteeks’treatment W:bodyweight;CI:confi Iawwawwaawwawwaww B rall<6≧6rall<6≧6rallrall<6≧6rall<6≧6rall<6≧6 dex; e e ee e e n v v vv v v i O O OO O O ass m y d o b MI: B me fat; y Outco BW BMI BF WC HC WHR BF:bod 10 Evidence-BasedComplementaryandAlternativeMedicine Study or subgroup Ear stimulation Placebo Weight Mean difference Year Mean difference Mean SDTotal Mean SD Total IV, random, 95% CI IV, random, 95% CI 7.2.1<6wk Lien et al. 2012 (AP) −1 1.1 24 −0.6 1.4 23 8.8% −0.40 [−1.12, 0.32] Lien et al. 2012 (AA) −1.3 2.2 24 −0.6 1.4 23 8.0% −0.70 [−1.75, 0.35] Kim et al. 2014 −3.1 0.73 25 −0.2 1.05 24 9.2% −2.90 [−3.41, −2.39] Richards and Marley 1998 −2.911.48 28 0.28 1.09 30 8.9% −3.19 [−3.86, −2.52] 1998 He et al. 2012 −1.031.16 30 −0.43 0.89 30 9.2% −0.60 [−1.12, −0.08] 2012 Subtotal (95% CI) 131 130 44.1% −1.58 [−2.82, −0.33] Heterogeneity:𝜏2=1.88;𝜒2=73.10,df=4 (P<0.00001);I2=95% Test for overall effect:Z=2.48(P=0.01) 7.2.2≥6wk Yeo et al. 2014 (5 points) −4.4 1.5 22 −2.2 1.9 15 7.8% −2.20 [−3.35, −1.05] Abdi et al. 2012 −3.66 2.97 86 −2.27 3.01 83 8.4% −1.39 [−2.29, −0.49] Darbandi et al. 2012 −2.8 5.83 43 −1.42 4.15 43 5.3% −1.38 [−3.52, 0.76] Hsu et al. 2009 −0.3 1.4 23 −0.5 2.2 22 8.0% 0.20 [−0.88, 1.28] Yeo et al. 2014 (1 point) −4.1 2.5 21 −2.2 1.9 15 7.0% −1.90 [−3.34, −0.46] Allison et al. 1995 −0.63 3.26 35 −1.28 2.74 34 7.1% 0.65 [−0.77, 2.07] 1995 Hsieh et al. 2011 −0.8 2.16 27 −0.01 0.3 28 8.6% −0.79 [−1.61, 0.03] 2011 Ching et al. 2012 −0.7 3.38 33 −0.5 8.53 39 3.8% −0.20 [−3.11, 2.71] 2012 Subtotal (95% CI) 290 279 55.9% −0.92 [−1.63, −0.22] Heterogeneity:𝜏2=0.55;𝜒2=16.91,df=7(P=0.02);I2=59% Test for overall effect:Z=2.56(P=0.01) Total (95% CI) 421 409 100.0% −1.21 [−1.94, −0.47] Heterogeneity:𝜏2=1.44;𝜒2=99.60,df=12(P<0.00001);I2=88% Test for overall effect:Z=3.23(P=0.001) −4 −2 0 2 4 Test for subgroup differences:𝜒2=0.81,df=1(P=0.37),I2=0% Favors [ear stimulation] Favors [placebo] Figure2:Theforestplotofoutcomemeasure“bodyweightchangemagnitude.”Comparison.Auricularstimulationversusplacebo.Subgroup analysisbytreatmentduration:shorterorlongerorequaltosixweeks. 𝑃 < 0.001; Figure 3), BF (MD: −0.83%; 95% CI: −1.43 to 0.00;Figure7)orlonger(MD:−0.01;95%CI:−0.08to0.07; −0.24;𝑃=0.006;𝐼2=0%;Figure4),andWC(MD:−1.75cm; Figure7)treatmentsubgroups. 95% CI: −2.95 to −0.55; 𝑃 = 0.004; 𝐼2 = 87%; Figure 5). NosignificantchangewasnotedinHC(MD:−1.89cm;95% 3.7. Results of the Metaregression. We further conducted a CI: −4.57 to 0.79; Figure 6) or WHR (MD: −0.01; 95% CI: metaregressiontoexplorepotentialinterstudyheterogeneity −0.02∼0.00;Figure7). in some of the pooled analyses. Participant characteristics such as sex and age; characteristics of the included publications such as modified Jadad score and dropout rate; 3.6. Results of the Subgroup Analysis. Across our included and treatment differences such as numbers of acupoints studies,thetreatmentlengthrangedfrom3to12weeks,with and the frequency of auricular stimulation were analyzed. anaverageof6.9weeks.Duetorelativelyhighheterogeneity, Total numbers of treatment were the only possible source weperformedasubgroupanalysisaccordingtotheinterven- ofheterogeneityinBMI,witha−0.083kg/m2 lossforevery tiondurationoflessthansixweeks(shorter)versusmorethan auricularstimulation(P=0.036)(Figure8). orequaltosixweeks(longer). BW decreased in both the shorter (MD: −1.58kg; 95% CI: −2.82 to −0.33; 𝑃 = 0.01; 𝐼2 = 95%; Figure 2) and the 3.8.PublicationBias. AfunnelplotandEgger’stestwereused longer(MD:−0.92kg;95%CI:−1.63to−0.22;𝑃=0.01;𝐼2= fortheevaluationofpotentialpublicationbias.ForBWand BMI,thePvalueofEgger’stestwaslowerthan0.05,indicating 59%;Figure2)treatmentsubgroups.Boththeshorter(MD: −0.48kg/m2; 95% CI:−0.92 to −0.04; 𝑃 = 0.03; 𝐼2 = 92%; thatpublicationbiasmayexist.ForBF,HC,WC,andWHR, there was no evidence of significant publication bias in our Figure 3) and longer (MD: −0.65kg/m2; 95% CI: −0.95 to meta-analysis(P>0.05,AppendixS4). −0.34; 𝑃 < 0.001; 𝐼2 =52%;Figure3)treatmentsubgroups alsoshowedadecreasedBMI.BeneficialchangesinWCwere 4.Discussion notedintheshortersubgroup(MD:−0.51cm;95%CI:−0.92 to −0.10; 𝑃 = 0.01; 𝐼2 = 0%; Figure 5) and in the longer Inthisstudy,wefocusedontheeffectsofauricularacupoint subgroup(MD:−2.19cm;95%CI:−3.83to−0.54;𝑃=0.009; stimulation in overweight and obese adults. We systemat- 𝐼2 =83%;Figure5).NopositiveeffectonHCwasobserved ically reviewed RCTs with a low risk of bias. Only RCTs intheshortersubgroup(MD:0.46cm:95%CI:−0.94to1.87; achieving a moderate to high quality score (greater than or Figure6).However,HCsignificantlydecreasedinthelonger equal to 4) using the modified Jadad scale were included treatmentsubgroup(MD:−3.41cm;95%CI:−6.03to−0.78; in our meta-analysis. Results of the meta-analysis suggest 𝑃 = 0.01; 𝐼2 = 91%). There was no significant reduction in that,inoverweightandobeseadultswithmoderatetohigh WHR in either the shorter (MD: −0.01; 95% CI: −0.02 to heterogeneity,auricularacupointstimulationhadsignificant

The Effect of Auricular Acupoint Stimulation in Overweight and Obese Adults: A Systematic Review ...

Similar The Effect of Auricular Acupoint Stimulation in Overweight and Obese Adults: A Systematic Review ...