THE TREATMENT OF OBESITY BY ACUPUNCTURE

The present study is an investigation of the results of the studies on the effects
of acupuncture application therapy on obesity. It has been reported that acupuncture
application in obesity treatment is effective in procuring weight loss.
It can affect appetite, intestinal motility, and metabolism, as well as emotional
factors such as stress. Increases in neural activity in the ventromedial nuclei of
the hypothalamus, in tone in the smooth muscle of the stomach and in levels of
enkephalin, beta endorphin, and serotonin in plasma and brain tissue have also
been observed with the application of acupuncture. It has been observed that
acupuncture application to obese people increases excitability of the satiety
center in the ventromedial nuclei of the hypothalamus. Acupuncture stimulates
the auricular branch of the vagal nerve and raises serotonin levels. Both of
these activities have been shown to increase tone in the smooth muscle of the
stomach, thus suppressing appetite. Among other things, serotonin enhances
intestinal motility. It also controls stress and depression via endorphin and
dopamine production. In addition to these effects, it is thought that the increase
in plasma levels of beta endorphin after acupuncture application can contribute
to the body weight loss in obese people by mobilizing the body energy depots
through lipolithic effect.
Keywords acupuncture, appetite, beta endorphin, enkephalin, obesity, Serotonin

INTRODUCTION
Obesity could well become the most common health problem of the 21st
century (Palou et al., 2000). Obesity is a disease resulting from the over
storage of fat in the body. It is a problem concerning the balance of energy.
An imbalance between energy input and energy consumption causes an increase
in the body fat rate (Palou et al., 2000). It is known that the prevalence
of obesity in adults and children has been increasing significantly around
the world (Weinstock et al., 1998). In this century, obesity has been seen
especially in industrial countries (Leonhardt et al., 1999). The over-consumption
of delicious, high-calorie food and decrease in physical activity play
major roles in increasing the prevalence of obesity in industrial countries
(Campfield et al., 1996; Hill & Peters, 1998). The cost of treatment of obesity
and obesity-related diseases is significant in general health expenditures
in the United States (Bray, 1998).
The general principles of obesity treatment are to obtain weight loss, to
maintain the reduced body weight after this loss, and to control the risk
factors of disease. At the onset of obesity treatment, a 10% body weight
reduction is targeted. After a one to two kg per week weight loss is observed
over 6 months, new goals can be determined (Lyznicki et al., 2001).
Treatments for obesity include: diet restriction, regulation of physical
activity, behavior treatment, pharmacotherapy, operation, or acupuncture application
or the use of any of these methods in combination (Cabýoglu &
Ergene, 2005; Ernst, 1997; Richards & Marley, 1998).
Complementary medicine is more popular than ever before. About one
third to one half of the general population uses some type of complementary
treatment. Acupuncture is among the most popular complementary treatments.

TREATMENT OF OBESITY BY ACUPUNCTURE APPLICATIONS
Cabýoglu and Ergene (2005) applied body and ear acupuncture for 20 days
to 22 women who had a body mass index (BMI) between 30 and 40 while a
1425 Kcal diet program was prepared for 21 women under the same circumstances.
Besides, there was a control group including 12 women. In this
study, associated with body weight, levels of the serum total cholesterol,
triglyceride, HDL cholesterol and LDL cholesterol in obese women were
examined. In acupuncture treatment, the Hungry and Shen Men ear points,
and the Hegu (LI 4), Quchi (LI 11), Tianshu (St 25), Zusanli (St 36), Neiting
(St 44) and Taichong (Liv 3) body points were used. There was a 4.8%
weight reduction in obese women with electroacupuncture application, whereas
obese women in diet restriction had a 2.5% weight reduction. There were
significant decreases in total cholesterol and triglycerides levels in EA and
diet groups compared with the control group. Furthermore, there was a decrease
in LDL levels in the EA group compared with those in the control
group.
Huang et al. (1996) applied auricular acupuncture and diet and aerobics
exercise programs for 8 weeks to 8 men who had a body mass index (BMI)
over 30 and body fat rate over 25% and to 37 women who had a BMI over
30 and body fat rate over 30%. In the auricular acupuncture application, the
points Shen Men, Stomach, Sanjiao, and Hungry were chosen. Weekly application
was made to a single ear each session, using one ear in one session
and the other ear in the next session. The diet program was prepared by a
dietician to meet the daily needs of the people participating in the study by
calculating their anticipated daily activities, as well as other factors. The
exercise program was arranged to be 3 to 5 times per week and to burn 300
to 500 kcal of energy in each session. As a result of this triple application, an
average 4.4 kg body weight loss and a 5.6% reduction in body fat rate were
observed.
Sun and Xu (1993) applied auricular and body acupuncture therapy to
110 obese patients. In this study, a small, spherical seed, a method employed
in traditional Chinese acupuncture, was applied to the auricular acupuncture
points, Mouth, Esophagus Stomach, Shen Men, Lung, and Endocrine in sessions
three to five days apart. This application was made first on one ear and
then on the other ear in the following session. Additional application was
made to the body acupuncture points Tianshu (St 25), Zusanli (St 36), Sanyinjiao
(Sp 6), Neiguan (P 6), and Fenglong (St 40). This application was performed
once every 3 to 5 days, in 15 min sessions over 3 months. As a result of
these applications, a 5.0 kg loss in body weight was observed.
Shafshak (1995) performed a study with 30 obese females, dividing them
into three groups each including 10 females. He applied electroacupuncture
to the Stomach points on both ears of the subjects in the first group, to the
Hungry points on both ears of the subjects in the second group, and to placebo
points on both ears of the subjects in the third group. These applications
continued once a day, five days a week, for three weeks. Also a diet of 1000
kcal/day was advised to patients. In the first group, 80% of the patients
managed to apply the diet. The rate of diet application for the second group
was 70%, whereas that of the third group was 20%. In all patients applying
the diet, the observed body weight loss was 1 to 4 kg in the first group, 1.5
to 3.5 kg in the second group and 1 to 3 kg in the third group. According to
the results of this study, it was observed that the auricular acupuncture points
Stomach and Hungry were effective in weight loss when compared with
placebo points.
Through electroacupuncture to obese people, increases in the serum triglyceride
and LDL cholesterol levels and a decrease in the serum HDL cholesterol
levels were reported by Lyznicki and his colleagues (2001). These
two levels are thought to have particular ties to cardiovascular disease. Liu et
al. (1992), using the ear and body acupuncture points of traditional Chinese
acupuncture, applied acupuncture to 102 obese people and studied the changes
in body weight and plasma levels of total cholesterol, triglycerides, HDL
cholesterol, and LDL cholesterol. Ear acupuncture was applied once every 5
days and body acupuncture was performed once every 3 days in 20-min
sessions over a 1 month period. In Liu’s study, a weight loss with a mean
value of 3.3 kg was noted. Also, decreases in plasma levels of total cholesterol,
triglyceride, and LDL cholesterol levels and an increase in the HDL
cholesterol level were observed. Sun and Xu (1993) performed ear and body
acupuncture to obese people and analyzed the changes in body weight and
levels of total cholesterol, triglyceride, and HDL cholesterol. They applied
acupuncture to the Mouth, Esophagus, Stomach, Shen Men, Endocrine, and
Lung acupuncture points on one ear once every three or five days, and on the
other ear in the next session by using small seeds that are used in some
traditional Chinese acupuncture methods. They also applied acupuncture to
the St 25, St 36, Sp 6, P 6, and St 40 body points once every three or five
days using acupuncture needles. In their study, it was observed that decreases
in plasma levels of total cholesterol and triglyceride corresponded with weight
loss. Therefore, they concluded that EA therapy may be a useful approach to
treatment of obesity and potentially decrease the risk factors associated with
obesity.
Stimulation of the Hungry point creates an increase of the fullness feeling
and a repression of the hunger feeling (Asomoto & Takeshige, 1992).
Stimulation of the Shen Men point regulates cerebral cortex function and has
a sedative effect (Wang & Kain, 2001). Stimulation of the Stomach point
stimulates the auricular branch of the vagal nerve, which has been shown to
increase tone in the smooth muscle of the stomach, thus suppressing appetite
(Richards & Marley, 1998). Stimulation of the LI 4, LI 11, and St 25 body
acupuncture points has a regulatory effect on intestinal motility (Maciocia,
1989), whereas stimulation of St 36 and St 44 increases excitability of the
satiety center in the ventral medial nucleus of the hypothalamus (Zhao et al.,
2000). In traditional Chinese medicine, the St 36 body acupuncture point has
been used for the treatment of both diarrhea and constipation. This point has
been reported to regulate gastrointestinal motility by increasing motility in
people with hypoactive intestinal motility and conversely by decreasing
motility in people with hyperactive intestinal motility (Li et al., 1992). Stimulation
of this point also increases the amplitude and frequency of gastric
peristalsis that shortens gastric emptying time and delays the contraction time
in regular people (Li et al., 1992).
ACUPUNCTURE APPLICATION AND SUPPRESSING APPETITE
In the treatment of obesity, acupuncture applications, especially auricular
acupuncture, are very effective for losing weight in obese people (Sun & Xu,
1993; Lei, 1988; Mulhisen & Rogers, 1999). Although diet application causes
weight loss in obesity treatment, it has no effect on suppression of appetite
(Richards & Marley, 1998). Many overweight people are aware that diets can
help with weight loss but have difficulty in suppressing their appetite. However,
it has been determined that acupuncture application is effective both in
weight loss (Zhan, 1993; Sun & Xu, 1993) and in suppression of appetite
(Shiraishi et al., 1995; Zhao et al., 2000).
Shiraishi et al. (1995) reported the changes in neural activity of the
ventromedial (VMH) and lateral hypothalamus (LH) through auricular acupuncture
application on normal and experimentally obese rats. One experimental
group of obese rats was obtained by destroying the ventromedial
hypothalamus and another through a high-calorie diet. Auricular acupuncture
application was performed to the region that was innerved by the nervous
vagus on a single ear. This region is called the cavum conchae on human
beings. Although the neural activity of the LH is diminished in normal rats
by auricular acupuncture application, the neural activity of the VMH is increased.
Likewise, neural activity of the LH was reduced in both of the two
experimental groups of obese rats, and neural activity of the VMH was increased
in the group of high-calorie diet, obese rats. As a result, it was
determined that auricular acupuncture application is effective in the formation
and protection of the satiety sense in both normal and obese rats.
Zhao et al. (2000) in their study on rats, applied electroacupuncture on
one side of the body on 1 day and on the other side the following day, for 12
days in 5-min daily sessions. For this test, they chose the Zusanli (St 36) and
Neiting (St 44) points. It was observed that electroacupuncture application on
rats increased excitability of the satiety center in the ventromedial nucleus of
the hypothalamus.
Wenhe and Yucan (1981) observed that the level of serotonin (5-HT) in
the central nervous system increased with acupuncture application (Figure 1).
Serotonin has been implicated in the control of eating behavior and body
weight. Stimulants of this monoamine reduce food intake and body weight,
increase energy expenditure (Curzon, 1990; Simansky, 1996), and enhance
intestinal motility (Guyton & Hall, 2001). This effect of 5-HT that reduces
food intake can be observed on 5-HT receptors of the satiety center in the
ventromedial nuclei of the hypothalamus (Sarah et al., 1998). Besides that, it
was noted that serotonin gave happiness, helped a person to feel good, controlled
the sexual motivation, and had a role in obtaining the psychomotor
balance (Guyton & Hall, 2001). Acupuncture stimulates the auricular branch
of the vagal nerve and raises serotonin levels. Both of these activities have
been shown to increase tone in the smooth muscle of the stomach, thus
suppressing appetite (Richards & Marley, 1998). It is thought that an increase
in the level of serotonin in the central nervous system with acupuncture
application can provide weight loss, as it has a role in both reducing
food intake and arranging the psychomotor balance.
ACUPUNCTURE, BETA ENDORPHIN,
AND LIPOLITIC ACTIVITY
In many studies it has been observed that electroacupuncture application caused
an increase in the levels of beta endorphin both in serum and in the central
nervous system (Jin et al., 1996; Takeshige et al., 1992, 1993; Fu, 2000; Petti
et al., 1998) (Figure 1). It has been determined that electroacupuncture application
with different current frequencies causes the secretion of different
endojen opioids. It also has been observed that low current frequency (2 Hz)
electroacupuncture application increases the concentration of endomorphins,
enkephalins, and beta endorphin but high current frequency (100 Hz) electroacupuncture
application increased the concentration of dynorphin in the central
nervous system (Han et al., 1999) (Figure 1).
The studies that showed the lipolitic activity of pro-opiomelanocortin
products were performed as in vivo and in vitro studies on animals (Schwandt,
1985; Richter et al., 1983; Richter & Schwandt, 1985). Richter et al. (1983)
investigated the lipolitic activity of beta endorphin in the isolated fat cells of
rabbits in vivo. It was determined that as a result of the effect of beta endorphin
 on fat cells, the levels of free fatty acid and glycerol increased in the rabbit
plasma. This effect was blocked by naloxone. Vettor et al. (1993) studied the
lipolitic activity of beta endorphin in isolated human fat tissue. In their study,
it was observed that whereas BE application caused the increase of glycerol
secretion from isolated fat cells, naloxone inhibited this effect.
According to the results obtained from these studies, it is thought that
electroacupuncture, which increases the plasma beta endorphin levels, can
contribute to the weight loss by increasing the lipolithic activity.

CONCLUSION
It has been observed that acupuncture application depresses the appetite by
activating the satiety center in the hypothalamus and increasing sympathetic
activity through an increase in the concentration of serotonin in the central
nervous system of obese people. Acupuncture stimulates the auricular branch
of the vagal nerve, which has been shown to increase tone in the smooth
muscle of the stomach, thus suppressing appetite. It also controls stress and
depression via endorphin and dopamine production. In addition to these
effects it is thought that the increases of plasma levels of beta endorphin
naturally occurring after acupuncture application can contribute to body weight
loss in obese people. This is accomplished by mobilizing the body energy
depots by lipolithic effect. Through these mechanisms, acupuncture application
can be seen as an effective therapy in the treatment of obesity.