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The Effect of Auricular Acupoint Stimulation in Overweight and Obese Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

1. Introduction

Obesity is an increasingly common chronic disease worldwide. Overweight and obesity represent a rapidly growing threat to the health in an increasing number of countries [1]. The prevalence of adult obesity in the United States was 34.9% based on data collected by the National Health and Nutrition Examination Survey between 2011 and 2012 [2]. Obesity and increased central fat increase the relative risk of hypertension, hypercholesterolemia, and diabetes mellitus [3] and increase morbidity and mortality [4, 5]. The basic anthropometric measurements for evaluating overweight and obese patients are body height, body weight (BW), body mass index (BMI), body fat (BF), waist circumference (WC), hip circumference (HC), and waist-to-hip ratio (WHR). Anthropometric measurements are reliable physical parameters to evaluate the effects of weight loss.

Weight loss provides a number of cardiac [6, 7] and noncardiac benefits [8], and a number of complementary therapies are used to treat overweight and obese individuals. Auricular acupoint stimulation, also called ear stimulation or auriculotherapy, is a method of diagnosing and treating physical and psychosomatic dysfunctions by stimulating a specific point in the ear. Many methods are used, such as finger acupressure, electrical stimulation, lasers, different types of needles, seeds, and magnetic balls [9]. Of these, auricular acupuncture by needle is the most common. Auricular acupuncture is a convenient method used to treat many conditions, such as substance abuse, pain, obesity, anxiety, epilepsy, and sleep disorders. Both experimental and clinical data suggest that auricular acupuncture has beneficial effects in combatting the mechanisms of obesity [10], but there are only a limited number of evidence-based trials [11]. Recent systematic reviews and meta-analyses concerning obesity have focused on body acupuncture [12], acupoint catgut embedding [13], and pharmacoacupuncture [14]. There has been little comprehensive information published focusing on auricular acupoint stimulation in the treatment of obesity. The aim of this study is to perform an updated systematic review and meta-analysis to evaluate the effect of auricular acupoint stimulation, including auricular acupuncture and auricular acupressure, on overweight and obese adults using anthropometric measurements.

2. Methods

This systematic review and meta-analysis were conducted in accordance with the PRISMA-P guidelines (Appendix S1).

2.1. Data Sources and Search Strategy. We searched the following databases from inception to April 2017: PubMed, EMBASE, Allied and Complementary Medicine Database (AMED), China National Knowledge Infrastructure (CNKI), and the PerioPath Index to Taiwan Periodical Literature. We used the keywords: "((Acupuncture, Ear) OR (auricular acupuncture) OR (auricular acupressure) OR (auricular acupoint stimulation) OR (auricular therapy) OR (moxibustion)) AND ((weight reduction) OR (overweight) OR (obesity))." Of these, "Acupuncture, Ear" and "obesity" are Medical Subject Headings Terms. We did not limit the language, year, or article type to enable a comprehensive and thorough search. We also did not restrict the search to humans or adults. Tzu-Lin Yeh and Shu-Jung Liu each conducted the search independently. Disagreements were resolved through discussion with the third author, Tsung-Ping Pai. The search strategy employed is available in Appendix S2.

2.2. Study Selection and Methodological Quality Assessment. We included all publications fitting the purposes of our study that followed our inclusion eligibility criteria: (1) randomized controlled trials (RCTs) focused on overweight and obese human adults; (2) no effective treatment in the control arm besides lifestyle modification; (3) the acupoints in the intervention group that were restricted to the ears; and (4) outcome measurements that include at least one anthropometric measurement, either as a primary or as secondary outcome of the paper. We excluded articles that were (1) irrelevant to the topic or target population; (2) duplicate publications; (3) trials of a cross-over study; or (4) confounded by other factors like effective body acupuncture, medication, or other traditional Chinese medicine in the intervention or control arm.

Authors Tzu-Lin Yeh and Hsin-Hao Chen independently used the modified Jadad scale to assess the methodological quality of each included study. The modified Jadad scale includes eight items to evaluate randomization, blinding, withdrawals, dropouts, inclusion and exclusion criteria, adverse reactions, and statistical analysis [15]. The score of each study ranges from zero (the lowest quality) to eight (the highest quality). Studies were classified as good to excellent (high quality) if they had a score of four or more. The detailed scores of each study are summarized in Appendix S3. If the two authors had different opinions when assessing and selecting the studies to include, agreement was reached by consensus with the third author, Tsung-Ping Pai. The study flow diagram is shown in Figure 1.

2.3. Data Extraction and Analysis. Tzu-Lin Yeh and Tsung-Ping Pai independently extracted the data from all included studies, and the following data were collected: first author's name, year of publication, study size, population characteristics, mean age, sex ratio, type of acupuncture, acupoint selection, treatment frequency, treatment duration, control group method, clinical outcome measurements, and adverse effects (Table 1).

Data were analyzed using the mean difference (MD) with 95% confidence intervals (CI) for continuous outcomes. RevMan version 5.3 software (Cochrane Collaboration) was used for all data analyses. The meta-analysis was conducted when the trials had acceptable clinical homogeneity and statistical heterogeneity. A random effect model was employed using DerSimonian and Laird's method due to the significant heterogeneity expected among the studies [16]. Heterogeneity was quantified using the Cochran Q test and [I.sup.2] statistics [17,18], and subgroup analyses were performed for different study settings. Metaregression was also performed using Comprehensive Meta-Analysis ver. 3 software (Biostat Inc., Englewood, NJ, USA) to explore the possible sources of heterogeneity. Potential publication bias was analyzed with a funnel plot and Egger's test [19].

3. Results

3.1. Study Characteristics. Figure 1 illustrates the search process and outcomes. A total of 18 RCTs were included for systematic review [20-37]. We assessed their quality using the modified Jadad scale. Characteristics of the included trials and total modified Jadad scores are shown in Table 1. Two RCTs [24, 25] had the same study population group, and the duplicated population was excluded when we reported the overall population size. We included both articles in our meta-analysis because they had different outcome measurements and did not interfere with our statistics.

All of the RCTs were published between 1995 and 2016. A total of 1775 participants were included, with a female to male ratio of 3: 1, and a mean age of 38.9 years old. Six studies were conducted in Taiwan [23-25, 28, 31, 36], three studies each in China [26, 30, 37] and Iran [27, 29, 32], two studies in South Korea [33, 35], and one RCT in the USA [20], Egypt [21], Australia [22], and Austria [34].

3.2. Intervention. The intervention methods varied among the studies included. One trial in 1998 used an AcuSlim acupuncture device with electrical stimulation to the auricular acupoint [22]. Six RCTs [21, 23, 26, 31, 34, 35, 37] used traditional auricular acupuncture with stainless steel needles, and two of these also used electrical stimulation [21,34]. Most of the included articles performed auricular acupressure with other devices such as Sinapis alba seeds [33], metal beads [31], Vaccaria seeds [25, 27-30, 32, 36, 37], an Acu-Stop 2000 device [20], or a Japanese Magnetic Pearl [25]. One of these RCTs also used electrical stimulation [36]. One trial [24] compared two different auricular acupressure devices (Japanese Magnetic Pearl and Vaccaria seeds) with a placebo. The number of auricular acupoints varied from one to six, with an average of 3.9. The most commonly used acupoints were Shen Men (TF4) and Stomach (CO4). Treatment length ranged from 3 to 12 weeks, with an average of 6.9 weeks.

3.3. Controls. Various sham acupuncture methods were used in the control arms of our included studies. No intervention was mentioned in two trials [30, 33]. One study in 1995 [20] and one trial in 1998 [22] used irrelevant acupuncture points in the wrist and thumb. Four articles used nonacupoints [21, 26, 36, 37]. Several studies used placebo needles or pseudo-interventions, including surgical tape [24, 25, 28], needles without needle points [23, 31], acupressure devices without seeds [27, 29], or electric stimulation with no power supply [34]. One study used superficial needling of the same points used in the treatment arm by removing the needles immediately after insertion [35].

3.4. Outcome Measures. Every RCT enrolled in this study included anthropometric measurements. In addition, seven trials [23, 24, 26, 27, 31, 36, 37] investigated biochemical characteristics and five studies [23, 26, 29, 31, 36] evaluated obesity-related hormone peptides. Psychological factors were evaluated using self-administered questionnaires in two studies [31, 33]. One publication [22] investigated appetite changes. Our objective was to ascertain the effect of auricular acupoint stimulation on anthropometric measurements, specifically.

3.5. Results of Meta-Analysis. Two studies [34, 36] did not have sufficient data to perform a meta-analysis. We contacted the authors, but there was no raw data available. Three articles had a relatively low Jadad score of 3 and thus were excluded from our meta-analysis [21,26, 37]. Eventually, thirteen RCTs that achieved a modified Jadad score greater than or equal to four were included in our meta-analysis. The meta-analysis results are shown in Table 2.

Overall, the meta-analysis showed a significant reduction in BW, with an MD of -1.21kg, a 95% CI of -1.94 to -0.47, P = 0.001, and [I.sup.2] = 88% (forest plots are shown in Figure 2). The meta-analysis also showed a significant reduction in BMI (MD: -0.57 kg/[m.sup.2]; 95% CI: -0.82 to -0.33; [I.sup.2] = 78%; P < 0.001; Figure 3), BF (MD: -0.83%; 95% CI: -1.43 to -0.24; P = 0.006; 12 = 0%; Figure 4), and WC (MD: -1.75 cm; 95% CI: -2.95 to -0.55; P = 0.004; [I.sup.2] = 87%; Figure 5). No significant change was noted in HC (MD: -1.89 cm; 95% CI: -4.57 to 0.79; Figure 6) or WHR (MD: -0.01; 95% CI: -0.02-0.00; Figure 7).

3.6. Results of the Subgroup Analysis. Across our included studies, the treatment length ranged from 3 to 12 weeks, with an average of 6.9 weeks. Due to relatively high heterogeneity, we performed a subgroup analysis according to the intervention duration of less than six weeks (shorter) versus more than or equal to six weeks (longer).

BW decreased in both the shorter (MD: -1.58 kg; 95% CI: -2.82 to -0.33; P = 0.01; [I.sup.2] = 95%; Figure 2) and the longer (MD: -0.92 kg; 95% CI: -1.63 to -0.22; P = 0.01; [I.sup.2] = 59%; Figure 2) treatment subgroups. Both the shorter (MD: -0.48 kg/[m.sup.2]; 95% CI: -0.92 to -0.04; P = 0.03; [I.sup.2] = 92%; Figure 3) and longer (MD: -0.65 kg/[m.sup.2]; 95% CI: -0.95 to -0.34; P < 0.001; [I.sup.2] = 52%; Figure 3) treatment subgroups also showed a decreased BMI. Beneficial changes in WC were noted in the shorter subgroup (MD: -0.51 cm; 95% CI: -0.92 to -0.10; P = 0.01; [I.sup.2] = 0%; Figure 5) and in the longer subgroup (MD: -2.19 cm; 95% CI: -3.83 to -0.54; P = 0.009; [I.sup.2] = 83%; Figure 5). No positive effect on HC was observed in the shorter subgroup (MD: 0.46 cm: 95% CI: -0.94 to 1.87; Figure 6). However, HC significantly decreased in the longer treatment subgroup (MD: -3.41 cm; 95% CI: -6.03 to -0.78; P = 0.01; [I.sup.2] = 91%). There was no significant reduction in WHR in either the shorter (MD: -0.01; 95% CI: -0.02 to 0.00; Figure 7) or longer (MD: -0.01; 95% CI: -0.08 to 0.07; Figure 7) treatment subgroups.

3.7. Results of the Metaregression. We further conducted a metaregression to explore potential interstudy heterogeneity 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; and treatment differences such as numbers of acupoints and the frequency of auricular stimulation were analyzed. Total numbers of treatment were the only possible source of heterogeneity in BMI, with a -0.083 kg/[m.sup.2] loss for every auricular stimulation (P = 0.036) (Figure 8).

3.8. Publication Bias. A funnel plot and Egger's test were used for the evaluation of potential publication bias. For BW and BMI, the P value of Egger's test was lower than 0.05, indicating that publication bias may exist. For BF, HC, WC, and WHR, there was no evidence of significant publication bias in our meta-analysis (P > 0.05, Appendix S4).

4. Discussion

In this study, we focused on the effects of auricular acupoint stimulation in overweight and obese adults. We systematically reviewed RCTs with a low risk of bias. Only RCTs achieving a moderate to high quality score (greater than or equal to 4) using the modified Jadad scale were included in our meta-analysis. Results of the meta-analysis suggest that, in overweight and obese adults with moderate to high heterogeneity, auricular acupoint stimulation had significant beneficial effects on the anthropometric parameters of BW, BMI, BF, and WC, while it showed less of an effect on HC and WHR. Heterogeneity improved after performing the subgroup analysis for the different treatment durations. After performing the subgroup analysis, only auricular stimulation of longer than 6 weeks produced a favorable effect on HC. Compared to shorter treatment durations, longer treatments of more than six weeks resulted in further decrease of BMI, WC, and HC. A linear effect was noted on BMI as the number of auricular stimulations increased.

A number of complementary therapies have been proposed in the treatment of overweight and obese individuals. A previous review found that acupuncture had some beneficial effects on obesity compared to a placebo or lifestyle control [10]. However, these results are of limited value due to the poor methodological quality of the included studies [38]. Another previous systematic review in 2012 focused on Chinese medicine and acupuncture in the treatment of obesity and reported that acupuncture was more effective than a placebo or lifestyle modification in reducing BW [39]. A total of 47 studies were included to evaluate the effects of acupuncture on obesity, but most of the included studies had a relatively low Jadad score of 1 to 3 points. Only one study, in 1998, had a Jadad score of 5, and this study was included in the present systematic review [22].

A recent meta-analysis performed in 2017 also indicated that acupuncture is an effective treatment for obesity [12]. However, the article emphasized body acupuncture, and BMI was the only reported outcome. Furthermore, twelve out of the 21 studies included had unclear randomization and only two studies achieved a score of 4 on the Jadad scale. An asymmetric funnel plot indicates the potential for publication bias.

Our main findings are consistent with an earlier systematic review and meta-analysis that focused on auricular acupuncture [40]. The article concluded that the effect of auricular acupuncture in combination with diet and exercise was more effective than auricular acupuncture alone. We used all of the articles included, except one [41], in the present review. The target population of the previous review was obese and nonobese adults, which was incongruent with our study's purposes. Furthermore, the authors did not perform a subgroup analysis, and all of their interventions were defined as auricular acupuncture. We considered several of these RCTs [20, 25, 27, 29, 30] as auricular acupressure in our review and subgroup analysis. Furthermore, in the previous review, only five articles were included in the meta-analysis and BW was the only reported outcome.

In the present review, our aim was to provide new evidence for auricular acupoint stimulation and to report comprehensive anthropometric parameters. Our strategy has several strengths. First, all of our included publications used a randomized placebo-controlled design, which reduces the risk of bias. Second, all of the articles were critically appraised using the modified Jadad scale and had a relatively high score of greater than or equal to four. Third, to the best of our knowledge, this systematic review included the first meta-analysis focused on auricular acupoint stimulation in overweight and obese adults. Finally, we comprehensively report a number of anthropometric parameters and how they were affected.

There are also several limitations to this study. First, most of the participants in our included studies were middle-aged Asian women. Our conclusions may be appropriate for this population, but the current evidence may not provide a strong case in other populations. Second, there was substantial heterogeneity. We explored the possible sources of this heterogeneity by conducting a subgroup analysis. The significant variations in acupoint selection, type of auricular therapy, treatment duration, and study endpoints are likely responsible for the heterogeneity in our meta-analysis.

Auricular stimulation may be involved in several mechanisms of BW regulation and obesity such as anorexigenic and orexigenic peptides, glucose metabolism, insulin resistance, lipid metabolism, and inflammatory markers [10]. Part of the cavum conchae is innervated by the auricular branch of the vagal nerve [42] which is stimulated in order to achieve a degree of appetite suppression [22]. Stimulation of cholinergic nerves may reduce plasma glucose levels [43] and improve insulin resistance [44] through serotonin-induced secretion of [beta] endorphin from the adrenal gland [45] and insulin growth factor-1 [10]. It also suppresses the innate inflammatory response via the acetylcholine-induced suppression of cytokine synthesis [46]. In an animal study, activation of this pathway significantly improved glucose homeostasis and insulin sensitivity via the suppression of adipose tissue inflammation without changes in body weight in both genetically obese and diet-induced obese mice [47].

Traditionally, auricular acupuncture includes needle insertion with or without the application of electrical stimulation to ear acupoints [48]. In contrast, acupressure does not involve needles and does not usually result in strong painful sensations. Acupressure often involves using various plant seeds or magnetic pellets taped onto both ears to stimulate acupoints. The various types of acupressure may explain why heterogeneity improved in the acupuncture subgroup but was still present in the acupressure subgroup. Acupressure is relatively noninvasive, low-cost, and self-managed. Once the seeds have been applied, they can remain on the ears for up to one month, depending on skin condition. Patients can stimulate these acupoints by pressing them with fingers as directed to achieve acupuncture-like effects.

Although the effect of anthropometric parameters changes was not large, studies have reported health benefits with a weight loss of only 3~5 percent of BW and complications of obesity could be reversed [6,49]. In our study, longer treatments had a more favorable effect in BMI, WC, and HC than shorter treatment durations. The more the number of treatments is, the more the BMI decreased. Therapeutic lifestyle modification along with more auricular acupoint stimulations with longer treatment durations may be a choice for obese and overweight adults.

The selection of acupoints is key for treatment success [50]. Only a few qualified studies have discussed treatment outcome differences depending on acupoint selection. The number and location of acupuncture points varied in the RCTs included in the present study. Ear charts vary in somatotopic arrangement, so it is necessary for therapists to gather more data to form recommendations for an international standard of auricular acupoints [51]. Treatment duration is another important factor affecting outcome. In our meta-analysis, treatment duration was short and treatment frequency varied. It has been reported that two to ten weeks of auricular therapy provides treatment benefits [52], although evidence for this is still insufficient. In addition, sham intervention designs have yet to be standardized. Sham acupuncture methods can be broadly categorized into five approaches [53, 54]: superficial needling of the same points used in the treatment arm; needling of irrelevant acupuncture points; needling nonacupoints; using placebo needles; and employing pseudo-interventions. Unlike body acupuncture, it is more difficult to locate nonacupoints in the ear for certain sham interventions due to the small size of the ear and large number of identified acupoints. There have been no solid conclusions concerning which design is the most appropriate to use in a control group [53], further increasing the heterogeneity between studies. Future studies should focus on larger populations, emphasize standardized auricular acupoint stimulation, and use standard sham methods with a modest treatment duration and frequency to ensure that eligible RCTs provide good quality evidence.

5. Conclusion

This meta-analysis shows that auricular acupoint stimulation improves physical anthropometric parameters including BW, BMI, BF, and WC in overweight and obese adults. These treatments have less of an effect on HC and WHR. But auricular stimulation longer than 6 weeks had a favorable effect on HC after performing a subgroup analysis. A linear effect was noted on BMI as the number of auricular stimulations increased. Therefore, we recommend more auricular acupoint stimulations of longer than 6 weeks as an alternative treatment for overweight and obese adults.

https://doi.org/10.1155/2017/3080547

Disclosure

All authors had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflicts of Interest

All authors declare that there are no conflicts of interest regarding the publication of this article.

Authors' Contributions

Tzu-Lin Yeh conceived the study objective and conceptualization, performed the statistical analysis and investigation, and interpreted the results. Tzu-Lin Yeh, Hsin-Hao Chen, and Tsung-Ping Pai contributed to the methodology, data collection, and validation. Tzu-Lin Yeh, Fang-Ju Sun, Shu-Jung Liu, and Shang-Liang Wu carried out formal analysis. Tzu-Lin Yeh, Hsin-Hao Chen, Shu-Jung Liu, and Shang-Liang Wu helped to outline the manuscript, participated in the study design, and drafted the manuscript. Lee-Ching Hwang supervised and coordinated. All authors read and approved the final version.

Acknowledgments

The authors would like to thank Dr. Ching-Hui Chen and Dr. Yu-Wei Tsao for sharing their library resource. The authors also appreciate the kindness of Mr. Stefan Schultze and Mr. Denis Xynkin for reading the paper written in German and Russian. Thanks are due to Dr. Wei-Te Lei for kindly performing the metaregression and Egger's test.

Supplementary Materials

Appendix S1, Table 1. PRISMA checklist. Appendix S2, Table 2. Search strategy. Appendix S3, Table 3. Detailed modified Jadad scale of each included studies. Appendix S4, Figure 1. The funnel plot and Egger's test to identify publication bias. Appendix S4, Figure 1. The funnel plot and Egger's test to identify publication bias. BW, body weight; BMI, body mass index; BF, body fat; WC, waist circumference; HC, hip circumference; WHR, waist-to-hip ratio. (Supplementary Materials)

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Tzu-Lin Yeh, (1) Hsin-Hao Chen, (1) Tsung-Ping Pai, (2) Shu-Jung Liu, (3) Shang-Liang Wu, (4) Fang-Ju Sun, (5) and Lee-Ching Hwang (2)

(1) Department of Family Medicine, Hsinchu MacKay Memorial Hospital, No. 690, Section 2, Guangfu Road, East District, Hsinchu City, Taiwan

(2) Department of Family Medicine, Taipei MacKay Memorial Hospital, No. 92, Section 2, Zhongshan North Road, Taipei City, Taiwan

(3) Department of Medical Library, MacKay Memorial Hospital, Tamsui Branch, No. 45, Minsheng Road, Tamsui District, New Taipei City, Taiwan

(4) School of Medicine, Griffith University, Gold Coast Campus, Parklands Dr., Southport, QLD 4215, Australia

(5) Department of Medical Research, MacKay Memorial Hospital, No. 92, Section 2, Zhongshan North Road, Taipei City, Taiwan

Correspondence should be addressed to Lee-Ching Hwang; hlc@mmh.org.tw

Received 12 June 2017; Revised 11 August 2017; Accepted 22 August 2017; Published 5 December 2017

Academic Editor: Kieran Cooley

Caption: Figure 1: Flowchart of the trial selection process.

Caption: Figure 8: Regression of numbers of auricular stimulation treatment on body weight. Std diff, standard difference.
Table 1: Characteristics of the included studies.

                                              Modified
Study (year)       Country     Population      Jadad     Sample
                                               score      size

Allison et al.       USA          Obese          5         96
(1995) [20]                      adults

Shafshak                          Obese
(1995) [21]         Egypt        female          3         30
                                 adults

Richards                       Overweight
and Marley        Australia      adults          7         60
(1998) [22]

                                 Obese
Hsu et al.         Taiwan        female         7.5        45
(2009) [23]                      adults

Hsieh              Taiwan      Overweight
(2010) [24]                    adolescents       4         84

Hsieh et al.        China      Overweight        3        200
(2011) [26]                      adults

                                 Young
Hsieh et al.                   adults with
(2011) [25]        Taiwan      abdominal         4         55
                                 obesity

Abdi et al.         Iran       Overweight        4        169
(2012) [27]                      adults

                               Overweight
Ching et al.                  schizophrenia
(2012) [28]        Taiwan       patients        7.5        72

Darbandi et al.
(2012) [29]         Iran       Overweight        6         86
                                 adults

                                  Obese
He et al.           China        female         4.5        60
(2012) [30]                      adults

                                  Obese
Lien et al.        Taiwan        female         7.5        71
(2012) [31]                      adults

Darbandi et
al. (2014) [32]     Iran       Obese male       7.5        40
                                 adults

                                  Obese
Kim et al.                       female
(2014) [33]        South          young          5         49
                    Korea        adults

Schukro et al.                    Obese
(2014) [34]        Austria       female          7         42
                               individuals

Yeo et al.         South       Overweight       6.5        58
(2014) [35]         Korea        adults

Yeh et al.                       Obese
(2015) [36]        Taiwan        adults         7.5        70

Hsu (2016)          China      Overweight        3        120
[37]                             adults

                  Characteristics   Intervention      Control
Study (year)      of participants   group             group
                   (gender, age)    treatment         treatment

                                                      Subjects
                                    AA device         received wrist
                                    (Acu-Stop         acupressure
Allison et al.       16 M/80F       2000) on          device in
(1995) [20]            41.1         dominant ear,     dominant
                                    massaged, 4       side
                                    times a day       massaged, 4
                                                      times a day

                                    Stainless         Stainless
                                    needle AA         needle AA
                                    with ES to API    with ES to
Shafshak          0 M/30 F 21-35    or AP2. ES        sham AP on
(1995) [21]                         duration = 25     ear
                                    mins API: CO4     ES duration =
                                    AP2: HG           25 mins

                                    ES with           ES with
                                    AcuSlim           AcuSlim
Richards              NR >18        device to AP      device to
and Marley                          ES duration =     thumb
(1998) [22]                         15-20 mins        (without AP)
                                    AP: CO4,          ES duration =
                                    TF4               15-20 mins

                                    Stainless steel
                                    needle (0.2 cm    Sham AA
                                    needle point)     using placebo
                                    to AP; no apply   needles
Hsu et al.            0M/45F        any pressure to   (without
(2009) [23]       39.5 [+ or -]     AP AP: CO4,       needle point)
                       12.0         CO18, HG,         AP: CO4,
                                    TF4               CO18, HG,
                                                      TF4

                                    Auricular
                                    acupressure       Acupressure
Hsieh             8 M/76 F 18-20    to Japanese       tape (0.5 *
(2010) [24]                         Magnetic          0.5 cm) on ear
                                    Pearl or
                                    Vaccaria
                                    seeds

                                    Vaccaria
                                    seeds to AP;
                                    applied
                                    pressure to       Needle AA
Hsieh et al.            NR          each AP for       on sham AP
(2011) [26]            18-65        30-50 times       on the body
                                    before eating
                                    AP: CO4,
                                    CO17, CO18,
                                    TF4

                                    Acupressure       Adhesive
                                    with Japanese     tape to AP
Hsieh et al.      5 M/50 F 18-20    Magnetic          AP: CO1,
(2011) [25]                         Pearl on AP       CO4, CO6,
                                    AP: CO1,          CO18, TF4
                                    CO4, CO6,
                                    CO18, TF4

                                    Ear pressing
                                    plaster with
                                    seed to AP
                                    Apply             Ear pressing
                                    pressure to       plaster
Abdi et al.             NR          AP before         without seed
(2012) [27]             38          eating for        to sham AP
                                    20 sec            AP: AH5,
                                    AP: CO1,          CO2, CO13
                                    CO4, CO17,
                                    HG, HX1,
                                    TF4

                                    Vaccaria
                                    seeds to AP.
                                    Apply pressure to Surgical tape
Ching et al.      33 M/39 F 47.8    AP before         to AP. AP
(2012) [28]                         eating            points were
                                    Each AP for       not pressed
                                    1 min             AP: CO4,
                                    AP: CO4,          CO18, HG,
                                    CO18, HG,         TF4
                                    TF4

                                    Vaccaria
                                    seeds to AP.
                                    Apply             Ear plaster
Darbandi et al.                     pressure to       without seeds
(2012) [29]          12 M/74 F      AP before         to AP
                  37.7 [+ or -]     eating            AP: AH5,
                        9.5         AP: CO1,          CO2, CO13,
                                    CO4, CO17,        Nose
                                    HG, HX1,
                                    TF4

                                    Vaccaria
                                    seeds to AP.
                                    Apply
                                    pressure on
He et al.             0M/60F        each seed for     No AA
(2012) [30]             34          30 sees/day
                                    AP: CO4,
                                    CO7, CO13,
                                    CO18, HG,
                                    TF4

                                                      Sham AA to
                                    Apply             AP with
                                    stainless         auricular
                                    needles with      needle with
                                    a 0.2 cm tip      tips removed
Lien et al.          0 M/71 F       or magnetic       (needle
(2012) [31]       40.7 [+ or -]     metal beads       without
                       11.3         to AP             needle
                                    AP: CO4,          points)
                                    CO18, HG,         AP: CO4,
                                    TF4               CO18, HG,
                                                      TF4

                                    Vaccaria          Sham AA
                                    seeds to AP       with plasters
                                    on both ears      to AP on both
Darbandi et                         for 3 days.       ears for 3
al. (2014) [32]        40 M         Apply             days. Apply
                       38.5         pressure to       pressure to
                                    AP before         AP before
                                    eating            eating AP:
                                    AP: CO1,          CO2, CO13,
                                    CO4, CO17,        AH5
                                    HG, HX1,
                                    TF4

                                    Three Sinapis
                                    alba seeds to
                                    each AP.
                                    Apply
                                    pressure to
Kim et al.        0 M/49 F 20.7     AP for 5 sees
(2014) [33]        [+ or -] 1.1     * 10              NO AA
                                    times/point,
                                    three
                                    courses/day
                                    AP: CO1,
                                    CO4, CO6,
                                    TF4

                                                      P-Stim[R]
Schukro et al.                      ES with a         dummy (no
(2014) [34]          0 M/42 F       P-Stim device     power
                                    AP: CO4,          supply)
                                    CO7, HG           AP: CO4,
                                                      CO7, HG

                                    Acupuncture       Sham AA,
                                    needle on         removed
                                    AP1 or AP2        immediately
Yeo et al.           6 M/52 F       AP1: CO1,         after
(2014) [35]       38.6 [+ or -]     CO4, CO6,         insertion; AP:
                       11.8         CO18, HX1;        CO1, CO4,
                                    AP2: HG           CO6, CO18,
                                                      HX1

                                    ES to AP and      ES to sham
                                    then apply        AP. Apply
                                    pressure to       pressure to
                                    each AP with      each AP with
                                    Vaccaria          Vaccaria
Yeh et al.        35 M/35 F 31.3    seeds for         seeds for
(2015) [36]        [+ or -] 8.8     1 min * 4         1 min * 4
                                    times/day         times/day
                                    AP: CO4,          AP: AH3,
                                    CO18, HG,         SF3, SF4,
                                    TF4               SF6

                                    Vaccaria
                                    seeds to AP
                                    on each ear       Needle AA to
Hsu (2016)           73 M/47 F      alternating       sham AP on
[37]               38.7 [+ or -]    every 2 days      body
                       10.0         AP: CO17,
                                    CO18, HG,
                                    TF4

                   Frequency/                            Adverse
Study (year)        treatment       Main outcome         effect
                     course

                                  (1) BW, BF, BFM     3 bleeding
Allison et al.    Every 2 wks/    (2) BP              ears in
(1995) [20]          12 wks       (3) Compliance      treatment
                                                      group

Shafshak
(1995) [21]        Every day/     BW                  NR
                      3 wks

Richards                          (1) BW *
and Marley        Twice daily/    (2) Appetite        NR
(1998) [22]           4 wks       change *

                                  (1) BW, BMI,
                                  WC, HC
                                  (2) FBG, TG,        1 mild
                                  TCH, HDL-C,         inflamma-
Hsu et al.         Twice a wk/    LDL-C               tion; 9 mild
(2009) [23]           6 wks       (3) Insulin,        tenderness
                                  leptin,             cases
                                  adiponectin,
                                  ghrelin,
                                  HOMA-IR

Hsieh                             (1) BMI
(2010) [24]         NR/8 wks      (2) TCH, TG,        NR
                                  HDL-C, LDL-C

                                  (1) BW, BMI, BF
Hsieh et al.       Every two      (2) TCH, TG         NR
(2011) [26]       days/ 12 wks    (3) FINS,
                                  HOMA-IR

Hsieh et al.
(2011) [25]         NR/8 wks      BW, WC              NR

                                  (1) BW *, BMI *,
                                  BF *, WC *,
                                  HC *,WHR
                                  (2) FBG, TCH,
                                  TG, HDL-C,
Abdi et al.        Twice a wk/    LDL-C, hs-CRP       No adverse
(2012) [27]          12 wks       (3)                 effect
                                  Anti-HSP27 *,
                                  Anti-HSP60 *,
                                  Anti-HSP65 *,
                                  anti-HSP70 *

Ching et al.
(2012) [28]        Twice a wk/    BW, BMI, BF         NR
                      8 wks

Darbandi et al.                   (1) BW, BMI,
(2012) [29]        Twice a wk/    BFM                 No adverse
                      6 wks       (2) Leptin *        effect

He et al.          Every three    BW, BMI, WC         NR
(2012) [30]        days/4 wks

                                  (1) BW, BMI,
                                  WC, HC, WHR
                                  (2) FBG, TG,
                                  TCH, HDL-C,
                                  LDL-C               1 account of
Lien et al.        Three times    (3) Adiponectin,    dizziness
(2012) [31]        a wk/4 wks     insulin, ghrelin,   after AA
                                  Leptin,
                                  HOMA-IR
                                  (4) WHO BREF
                                  life-quality
                                  scores

Darbandi et
al. (2014) [32]   Twice a wk/     BW, BMI, BFM,       No adverse
                      6 wks       HC                  effect

                                  (1) BW *, BMI *,
Kim et al.                        BF, WHR
(2014) [33]       Weekly/4 wks    (2) Self-efficacy   NR
                                  scale *

Schukro et al.
(2014) [34]       Weekly/6 wks    BW *, BMI *,        NR
                                  BF

                                  (1) BW *, BMI *,
Yeo et al.        Weekly/8 wks    WC *, BFM *, BF     NR
(2014) [35]                       (2) BP

                                  (1) BMI
                                  (2) BP, TCH, TG
Yeh et al.                        (3) Adiponectin,
(2015) [36]       Weekly/10 wks   leptin              NR

                                  (1) BW, BMI, BF
Hsu (2016)        Every 2 days/   (2) TCH, TG         NR
[37]                 12 wks       (3) FINS,
                                  HOMA-IR

Values are expressed as the mean [+ or -] standard deviation. * P < 0.05
between treatment and control groups; AA: auricular acupuncture; anti-
HSP: anti-heat shock protein; AP: auricular acupoint; BF: body fat
percentage; BFM: body fat mass; BMI: body mass index; BP: blood
pressure; BW: body weight; ES: electrical stimulation; F: female; FBG:
fasting blood glucose; FINS: fasting insulin; HC: hip circumference;
HDL-C: high-density lipoprotein cholesterol; HOMA-IR: homeostasis
model assessment for insulin resistance; HR: heart rate; hs-CRP: high-
sensitivity C-reactive protein; LDL-C: low-density lipoprotein
cholesterol; M: male; min: minutes; NR: not reported; sec: second;
TCH: total cholesterol; TG: triglycerides; WC: waist circumference;
WHR: waist-to-hip ratio; wk: week; acupoints: ankle (AH3), hip (AH5),
mouth (CO1), esophagus (CO2), stomach (CO4), small intestine (CO6),
large intestine (CO7), spleen (CO13), San Jiao (CO17), endocrine
(CO18), hunger point (HG), center of ear (HX1), elbow (SF3), shoulder
(SF4), clavicle (SF6), Shen Men (TF4).

Table 2: The effect of auricular acupoint stimulation on
anthropometric measurements.

Outcome            Intervention            Studies, N   Participants

          Overall auricular stimulation        13           830
BW             <6 weeks' treatment             4            165
           [greater than or equal to]          9            665
                  weeks' treatment

          Overall auricular stimulation        12           718
BMI            <6 weeks' treatment             4            165
           [greater than or equal to]          8            553
                  weeks' treatment

BF        Overall auricular stimulation        5            363

          Overall auricular stimulation        10           608
WC             <6 weeks' treatment             4            165
           [greater than or equal to]          6            443
                  weeks' treatment

          Overall auricular stimulation        5            348
HC             <6 weeks' treatment             2             92
           [greater than or equal to]          3            256
                  weeks' treatment

          Overall auricular stimulation        5            367
WHR            <6 weeks' treatment             1             47
           [greater than or equal to]          4            320
                  weeks' treatment

Outcome            Intervention                 MD (95% CI)

          Overall auricular stimulation    -1.21 (-1.94, -0.47)
BW             <6 weeks' treatment         -1.58 (-2.82, -0.33)
           [greater than or equal to]      -0.92 (-1.63, -0.22)
                  weeks' treatment

          Overall auricular stimulation    -0.57 (-0.82, -0.33)
BMI            <6 weeks' treatment         -0.48 (-0.92, -0.04)
           [greater than or equal to]      -0.65 (-0.95, -0.34)
                  weeks' treatment

BF        Overall auricular stimulation    -0.83 (-1.43, -0.24)

          Overall auricular stimulation    -1.75 (-2.95, -0.55)
WC             <6 weeks' treatment         -0.51 (-0.92, -0.10)
           [greater than or equal to]      -2.19 (-3.83, -0.54)
                  weeks' treatment

          Overall auricular stimulation     -1.89 (-4.57, 0.79)
HC             <6 weeks' treatment          0.46 (-.0.94,1.87)
           [greater than or equal to]      -3.41 (-6.03, -0.78)
                  weeks' treatment

          Overall auricular stimulation     -0.01 (-0.02, 0.00)
WHR            <6 weeks' treatment          -0.01 (-0.02, 0.00)
           [greater than or equal to]       -0.01 (-0.08, 0.07)
                  weeks' treatment

Outcome            Intervention              P      [I.sup.2]

          Overall auricular stimulation    0.001       88%
BW             <6 weeks' treatment          0.01       95%
           [greater than or equal to]       0.01       59%
                  weeks' treatment

          Overall auricular stimulation    <0.001      78%
BMI            <6 weeks' treatment          0.03       92%
           [greater than or equal to]      <0.001      52%
                  weeks' treatment

BF        Overall auricular stimulation    0.006       0%

          Overall auricular stimulation    0.004       87%
WC             <6 weeks' treatment          0.01       0%
           [greater than or equal to]      0.009       83%
                  weeks' treatment

          Overall auricular stimulation     0.17       94%
HC             <6 weeks' treatment          0.52       0%
           [greater than or equal to]       0.01       91%
                  weeks' treatment

          Overall auricular stimulation     0.15       0%
WHR            <6 weeks' treatment          0.15       0%
           [greater than or equal to]       0.81       0%
                  weeks' treatment

BF: body fat; BMI: body mass index; BW: body weight; CI: confidence
interval; HC: hip circumference; MD: mean difference; WC: waist
circumference; WHR: waist-to-hip ratio.

Figure 2: The forest plot of outcome measure "body weight change
magnitude." Comparison. Auricular stimulation versus placebo. Subgroup
analysis by treatment duration: shorter or longer or equal to six
weeks.

Study or subgroup               Ear stimulation             Placebo

                           Mean     SD    Total   Mean     SD    Total

7.2.1 < 6 wk
Lien et al. 2012 (AP)       -1     1.1     24     -0.6    1.4     23
Lien et al. 2012 (AA)      -1.3    2.2     24     -0.6    1.4     23
Kim et al. 2014            -3.1    0.73    25     -0.2    1.05    24
Richards and Marley 1998   -2.91   1.48    28     0.28    1.09    30
He et al. 2012             -1.03   1.16    30     -0.43   0.89    30
Subtotal (95% CI)                          131                    130
Heterogeneity: [[tau].sup.2] = 1.88; [chi square] = 73.10,
  df = 4 (P < 0.00001); [I.sup.2] = 95%
Test for overall effect: Z = 2.48 (P = 0.01)

7.2.2 [greater than or
   equal to] 6wk
Yeo et al. 2014            -4.4    1.5     22     -2.2    1.9     15
  (5 points)
Abdi et al. 2012           -3.66   2.97    86     -2.27   3.01    83
Darbandi et al. 2012       -2.8    5.83    43     -1.42   4.15    43
Hsu et al. 2009            -0.3    1.4     23     -0.5    2.2     22
Yeo et al. 2014            -4.1    2.5     21     -2.2    1.9     15
  (1 point)
Allison et al. 1995        -0.63   3.26    35     -1.28   2.74    34
Hsieh et al. 2011          -0.8    2.16    27     -0.01   0.3     28
Ching et al. 2012          -0.7    3.38    33     -0.5    8.53    39
Subtotal (95% CI)                          290                    279
Heterogeneity: [[tau].sup.2] = 0.55; [chi square] = 16.91,
  df = 7 (P = 0.02); [I.sup.2] = 59%
Test for overall effect: Z = 2.56 (P = 0.01)

Total (95% CI)                             421                    409
Heterogeneity: [[tau].sup.2] = 1.44; [chi square] = 99.60,
  df = 12 (P < 0.00001); [I.sup.2] = 88%
Test for overall effect: Z = 3.23 (P = 0.001)
Test for subgroup differences: [chi square] = 0.81,
  df = 1 (P = 0.37), [I.sup.2] = 0%

Study or subgroup
                                        Mean difference
                           Weight     IV, random, 95% CI     Year

7.2.1 < 6 wk
Lien et al. 2012 (AP)       8.8%      -0.40 [-1.12, 0.32]
Lien et al. 2012 (AA)       8.0%      -0.70 [-1.75, 0.35]
Kim et al. 2014             9.2%     -2.90 [-3.41, -2.39]
Richards and Marley 1998    8.9%     -3.19 [-3.86, -2.52]    1998
He et al. 2012              9.2%     -0.60 [-1.12, -0.08]    2012
Subtotal (95% CI)           44.1%    -1.58 [-2.82, -0.33]
Heterogeneity: [[tau].sup.2] = 1.88; [chi square] = 73.10,
  df = 4 (P < 0.00001); [I.sup.2] = 95%
Test for overall effect: Z = 2.48 (P = 0.01)

7.2.2 [greater than or
   equal to] 6wk
Yeo et al. 2014             7.8%     -2.20 [-3.35, -1.05]
  (5 points)
Abdi et al. 2012            8.4%     -1.39 [-2.29, -0.49]
Darbandi et al. 2012        5.3%      -1.38 [-3.52, 0.76]
Hsu et al. 2009             8.0%      0.20 [-0.88, 1.28]
Yeo et al. 2014             7.0%     -1.90 [-3.34, -0.46]
  (1 point)
Allison et al. 1995         7.1%      0.65 [-0.77, 2.07]     1995
Hsieh et al. 2011           8.6%      -0.79 [-1.61, 0.03]    2011
Ching et al. 2012           3.8%      -0.20 [-3.11, 2.71]    2012
Subtotal (95% CI)           55.9%    -0.92 [-1.63, -0.22]
Heterogeneity: [[tau].sup.2] = 0.55; [chi square] = 16.91,
  df = 7 (P = 0.02); [I.sup.2] = 59%
Test for overall effect: Z = 2.56 (P = 0.01)

Total (95% CI)             100.0%    -1.21 [-1.94, -0.47]
Heterogeneity: [[tau].sup.2] = 1.44; [chi square] = 99.60,
  df = 12 (P < 0.00001); [I.sup.2] = 88%
Test for overall effect: Z = 3.23 (P = 0.001)
Test for subgroup differences: [chi square] = 0.81,
  df = 1 (P = 0.37), [I.sup.2] = 0%

Figure 3: The forest plot of outcome measure "body mass index change
magnitude." Comparison. Auricular stimulation versus placebo. Subgroup
analysis by treatment duration: shorter or longer or equal to six
weeks.

Study or subgroup              Ear stimulation             Placebo

                          Mean     SD     Total   Mean     SD     Total
7.4.1 < 6 wk
Kim et al. 2014           -1.23   0.34     25     -0.15   0.45     24
Lien et al. 2012 (AA)     -0.5     0.9     24     -0.2     0.5     23
Lien et al. 2012 (AP)     -0.4     0.4     24     -0.2     0.5     23
Darbandi et al. 2014       -1      0.4     20     -0.7     0.2     20
Subtotal (95% CI)                          93                      90
Heterogeneity: [[tau].sup.2] = 0.18; [chi square] = 35.75,
  df = 3 (P < 0.00001); [I.sup.2] = 92%
Test for overall effect: Z = 2.12 (P = 0.03)

7.4.2 [greater than or equal to] 6 wk
Yeo et al. 2014 (5 points)-1.7     0.6     22     -0.8     0.7     15
Darbandi et al. 2012      -0.99   3.47     43     -0.66   2.83     43
Hsu et al. 2009           -0.1     5.6     23     -0.3     0.9     22
Abdi et al. 2012          -1.66   1.76     86     -0.95   1.55     83
Yeo et al. 2014 (1 point) -1.6     0.9     21     -0.8     0.7     15
Hsieh 2010 (seeds)        -1.23   2.62     26     0.05     0.5     26
Hsieh 2010 (pearl)        -0.7    1.88     24     0.05     0.5     26
He et al. 2012            -0.39   0.43     30     -0.16   0.39     30
Subtotal (95% CI)                          275                     260
Heterogeneity: [[tau].sup.2] = 0.08; [chi square] = 14.57,
  df = 7 (P = 0.04); [I.sup.2] = 52%
Test for overall effect: Z = 4.16 (P < 0.0001)

Total (95% CI)                             368                     350
Heterogeneity: [[tau].sup.2] = 0.12; [chi square] = 50.50,
  df = 11 (P < 0.00001); [I.sup.2] = 78%
Test for overall effect: Z = 4.54 (P < 0.00001)
Test for subgroup differences: [chi square] = 0.38,
  df = 1 (P = 0.54), [I.sup.2] = 0%

Study or subgroup
                                      Mean difference
                          Weight    IV, random, 95% CI     Year
7.4.1 < 6 wk
Kim et al. 2014           12.3%    -1.08 [-1.30, -0.86]
Lien et al. 2012 (AA)      9.9%     -0.30 [-0.71, 0.11]
Lien et al. 2012 (AP)     11.9%     -0.20 [-0.46, 0.06]
Darbandi et al. 2014      12.6%    -0.30 [-0.50, -0.10]    2014
Subtotal (95% CI)         46.8%    -0.48 [-0.92, -0.04]
Heterogeneity: [[tau].sup.2] = 0.18; [chi square] = 35.75,
  df = 3 (P < 0.00001); [I.sup.2] = 92%
Test for overall effect: Z = 2.12 (P = 0.03)

7.4.2 [greater than or equal to] 6 wk
Yeo et al. 2014 (5 points) 9.7%    -0.90 [-1.33, -0.47]
Darbandi et al. 2012       2.7%     -0.33 [-1.67, 1.01]
Hsu et al. 2009            1.1%     0.20 [-2.12, 2.52]
Abdi et al. 2012           8.8%    -0.71 [-1.21, -0.21]
Yeo et al. 2014 (1 point)  8.5%    -0.80 [-1.32, -0.28]
Hsieh 2010 (seeds)         4.1%    -1.28 [-2.31, -0.25]    2010
Hsieh 2010 (pearl)         5.8%     -0.75 [-1.53, 0.03]    2010
He et al. 2012            12.5%    -0.23 [-0.44, -0.02]    2012
Subtotal (95% CI)         53.2%    -0.65 [-0.95, -0.34]
Heterogeneity: [[tau].sup.2] = 0.08; [chi square] = 14.57,
  df = 7 (P = 0.04); [I.sup.2] = 52%
Test for overall effect: Z = 4.16 (P < 0.0001)

Total (95% CI)            100.0%   -0.57 [-0.82, -0.33]
Heterogeneity: [[tau].sup.2] = 0.12; [chi square] = 50.50,
  df = 11 (P < 0.00001); [I.sup.2] = 78%
Test for overall effect: Z = 4.54 (P < 0.00001)
Test for subgroup differences: [chi square] = 0.38,
  df = 1 (P = 0.54), [I.sup.2] = 0%

Figure 4: The forest plot of outcome measure "body fat change
magnitude." Comparison. Auricular stimulation versus placebo.

Study or subgroup          Auricular stimulation            Placebo

                          Mean     SD     Total   Mean     SD     Total

Abdi et al. 2012          -1.82   3.43     86     -0.77   2.73     83
Yeo et al. 2014           -1.9     1.8     22     -0.7     2.6     15
  (5 points)
Kim et al. 2014           -1.14   2.85     25     -0.36   0.93     24
Yeo et al. 2014           -1.3     2.2     21     -0.7     2.6     15
  (1 point)
Ching et al. 2012          0.3    2.21     33      -1     8.33     39

Total (95% CI)                             187                     176

Heterogeneity: [[tau].sup.2] = 0.00; [chi square] = 2.88,
  df = 4 (P = 0.58); [I.sup.2] = 0%
Test for overall effect: Z = 2.74 (P = 0.006)

Study or subgroup
                                       Mean difference
                          Weight     IV, random, 95% CI     Year

Abdi et al. 2012           40.7%    -1.05 [-1.98, -0.12]
Yeo et al. 2014            15.4%     -1.20 [-2.72, 0.32]
  (5 points)
Kim et al. 2014            25.6%     -0.78 [-1.96, 0.40]
Yeo et al. 2014            13.5%     -0.60 [-2.22, 1.02]
  (1 point)
Ching et al. 2012          4.8%      1.30 [-1.42, 4.02]     2012

Total (95% CI)            100.0%    -0.83 [-1.43, -0.24]

Heterogeneity: [[tau].sup.2] = 0.00; [chi square] = 2.88,
  df = 4 (P = 0.58); [I.sup.2] = 0%
Test for overall effect: Z = 2.74 (P = 0.006)

Figure 5: The forest plot of outcome measure "waist circumference
change magnitude." Comparison. Auricular stimulation versus placebo.
Subgroup analysis by treatment duration: shorter or longer or equal to
six weeks.

                              Ear stimulation              Placebo
Study or subgroup
                          Mean     SD     Total   Mean     SD     Total

7.5.1 < 6 wk
Lien et al. 2012 (AA)     -2.2     4.1     24     -1.1     2.7     23
Lien et al. 2012 (AP)     -2.3     2.8     24     -1.1     2.7     23
He et al. 2012            -0.8    0.81     30     -0.37   0.89     30
Subtotal (95% CI)                          78                      76
Heterogeneity: [[tau].sup.2] = 0.00; [chi square] = 1.21,
  df = 2 (P = 0.54); [I.sup.2] = 0%
Test for overall effect: Z = 2.46 (P = 0.01)

7.5.2 [greater than or equal to] 6 wk
Yeo et al. 2014 (5 points)-4.1     1.9     22     -2.2     2.1     15
Yeo et al. 2014 (1 point) -2.6     2.2     21     -2.2     2.1     15
Abdi et al. 2012          -3.83   10.02    86     1.54    10.02    83
Hsu et al. 2009           -0.2     5.1     23     -2.3     4.8     22
Hsieh et al. 2011         -6.3    6.06     27     -0.64   1.98     28
Ching et al. 2012         -1.1    4.23     33     -0.7     7.9     39
Darbandi et al. 2014      -4.4      1      20     -0.9     1.7     20
Subtotal (95% CI)                          232                     222
Heterogeneity: [[tau].sup.2] = 3.75; [chi square] = 36.23,
  df = 6 (P < 0.00001); [I.sup.2] = 83%
Test for overall effect: Z = 2.60 (P = 0.009)
Total (95%CI)                              310                     298

Heterogeneity: [[tau].sup.2] = 2.80; [chi square] = 67.60,
  df = 9 (P < 0.00001); [I.sup.2] = 87%
Test for overall effect: Z = 2.86 (P = 0.004)
Test for subgroup differences: [chi square] = 3.76,
  df = 1 (P = 0.05), [I.sup.2] = 73.4%

Study or subgroup                      Mean difference
                          Weight     IV, random, 95% CI     Year

7.5.1 < 6 wk
Lien et al. 2012 (AA)      9.8%      -1.10 [-3.08, 0.88]
Lien et al. 2012 (AP)      10.9%     -1.20 [-2.77, 0.37]
He et al. 2012             13.1%     -0.43 [-0.86, 0.00]    2012
Subtotal (95% CI)          33.8%    -0.51 [-0.92, -0.10]
Heterogeneity: [[tau].sup.2] = 0.00; [chi square] = 1.21,
  df = 2 (P = 0.54); [I.sup.2] = 0%
Test for overall effect: Z = 2.46 (P = 0.01)

7.5.2 [greater than or equal to] 6 wk
Yeo et al. 2014 (5 points) 11.5%    -1.90 [-3.23, -0.57]
Yeo et al. 2014 (1 point)  11.2%     -0.40 [-1.82, 1.02]
Abdi et al. 2012           7.2%     -5.37 [-8.39, -2.35]
Hsu et al. 2009            7.5%      2.10 [-0.79, 4.99]
Hsieh et al. 2011          8.7%     -5.66 [-8.06, -3.26]    2011
Ching et al. 2012          7.6%      -0.40 [-3.27, 2.47]    2012
Darbandi et al. 2014       12.5%    -3.50 [-4.36, -2.64]    2014
Subtotal (95% CI)          66.2%    -2.19 [-3.83, -0.54]
Heterogeneity: [[tau].sup.2] = 3.75; [chi square] = 36.23,
  df = 6 (P < 0.00001); [I.sup.2] = 83%
Test for overall effect: Z = 2.60 (P = 0.009)
Total (95%CI)             100.0%    -1.75 [-2.95, -0.55]

Heterogeneity: [[tau].sup.2] = 2.80; [chi square] = 67.60,
  df = 9 (P < 0.00001); [I.sup.2] = 87%
Test for overall effect: Z = 2.86 (P = 0.004)
Test for subgroup differences: [chi square] = 3.76,
  df = 1 (P = 0.05), [I.sup.2] = 73.4%

Figure 6: The forest plot of outcome measure "hip circumference change
magnitude." Comparison. Auricular stimulation versus placebo. Subgroup
analysis by treatment duration: shorter or longer or equal to six
weeks.

Study or subgroup            Ear stimulation             Placebo

                         Mean     SD     Total   Mean     SD     Total

7.7.1 < 6 wk
Lien et al. 2012 (AA)    -0.9     2.9     24     -1.6     3.8     23
Lien et al. 2012 (aP)    -1.4     3.3     24     -1.6     3.8     23
Subtotal (95% CI)                         48                      46
Heterogeneity: [[tau].sub.2] = 0.00; [chi square] = 0.12,
  df = 1 (P = 0.73); [I.sup.2] = 0%
Test for overall effect: Z = 0.65 (P = 0.52)

7.7.2 [greater than
  or equal to] 6wk
Abdi et al. 2012         -4.17   6.21     86     0.11    5.47     83
Hsu et al. 2009          -1.2     1.9     23     -0.6     3.8     22
Darbandi et al. 2014     -5.3     0.8     20     -0.2     1.1     20
Subtotal (95% CI)                         129                     125
Heterogeneity: [[tau].sub.2] = 4.83; [chi square] = 22.50,
  df = 2 (P < 0.0001); [I.sup.2] = 91%
Test for overall effect: Z = 2.55 (P = 0.01)

Total (95% CI)                            177                     171
Heterogeneity: [[tau].sub.2] = 8.62; [chi square] = 66.26,
  df = 4 (P < 0.00001); [I.sup.2] = 94%
Test for overall effect: Z = 1.38 (P = 0.17)

Test for subgroup differences: [chi square] = 6.50,
  df = 1 (P = 0.01), [I.sup.2] = 84.6%

Study or subgroup
                                     Mean difference
                        Weight     IV, random, 95% CI     Year

7.7.1 < 6 wk
Lien et al. 2012 (AA)    19.5%     0.70 [-1.24, 2.64]
Lien et al. 2012 (aP)    19.3%     0.20 [-1.84, 2.24]
Subtotal (95% CI)        38.8%     0.46 [-0.94, 1.87]
Heterogeneity: [[tau].sub.2] = 0.00; [chi square] = 0.12,
  df = 1 (P = 0.73); [I.sup.2] = 0%
Test for overall effect: Z = 0.65 (P = 0.52)

7.7.2 [greater than
  or equal to] 6wk
Abdi et al. 2012         19.9%    -4.28 [-6.04, -2.52]
Hsu et al. 2009          19.8%     -0.60 [-2.37, 1.17]
Darbandi et al. 2014     21.5%    -5.10 [-5.70, -4.50]    2014
Subtotal (95% CI)        61.2%    -3.41 [-6.03, -0.78]
Heterogeneity: [[tau].sub.2] = 4.83; [chi square] = 22.50,
  df = 2 (P < 0.0001); [I.sup.2] = 91%
Test for overall effect: Z = 2.55 (P = 0.01)

Total (95% CI)          100.0%     -1.89 [-4.57, 0.79]
Heterogeneity: [[tau].sub.2] = 8.62; [chi square] = 66.26,
  df = 4 (P < 0.00001); [I.sup.2] = 94%
Test for overall effect: Z = 1.38 (P = 0.17)

Test for subgroup differences: [chi square] = 6.50,
  df = 1 (P = 0.01), [I.sup.2] = 84.6%

Figure 7: The forest plot of outcome measure "waist-to-hip ratio
change magnitude." Comparison. Auricular stimulation versus placebo.
Subgroup analysis by treatment duration: shorter or longer or equal to
six weeks.

Study or subgroup             Ear stimulation              Placebo

                          Mean     SD     Total   Mean     SD     Total

7.6.1 < 6 wk
Kim et al. 2014           -0.01   0.03     25     -0.01   0.02     24
Lien et al. 2012 (AA)     -0.01   0.04     24     0.003   0.03     23
Lien et al. 2012 (AP)     -0.01   0.03     24     0.003   0.03     23
Subtotal (95% CI)                          73                      70
Heterogeneity: [[tau].sup.2] = 0.00; [chi square] = 1.74,
  df = 2 (P = 0.42); [I.sup.2] = 0%
Test for overall effect: Z = 1.44 (P = 0.15)

7.6.2 [greater than or
   equal to] 6 wk
Abdi et al. 2012          -0.0008 0.74     86     0.01    0.08     83
Hsieh et al. 2011         -0.0068  0.2     27     0.002   0.11     28
Subtotal (95% CI)                          113                     111
Heterogeneity: [[tau].sup.2] = 0.00; [chi square] = 0.00,
  df = 1 (P = 0.98); [I.sup.2] = 0%
Test for overall effect: Z = 0.24 (P = 0.81)

Total (95% CI)                             186                     181
Heterogeneity: [[tau].sup.2] = 0.00; [chi square] = 1.74,
  df = 4 (P = 0.78); [I.sup.2] = 0%
Test for overall effect: Z = 1.46 (P = 0.15)
Test for subgroup differences: [chi square] = 0.00,
  df = 1 (P = 0.95), [I.sup.2] = 0%

Study or subgroup
                                      Mean difference
                          Weight     IV, random, 95% CI    Year

7.6.1 < 6 wk
Kim et al. 2014            45.0%     0.00 [-0.01, 0.01]
Lien et al. 2012 (AA)      22.4%    -0.01 [-0.03, 0.01]
Lien et al. 2012 (AP)      30.9%    -0.01 [-0.03, 0.00]
Subtotal (95% CI)          98.4%    -0.01 [-0.02, 0.00]
Heterogeneity: [[tau].sup.2] = 0.00; [chi square] = 1.74,
  df = 2 (P = 0.42); [I.sup.2] = 0%
Test for overall effect: Z = 1.44 (P = 0.15)

7.6.2 [greater than or
   equal to] 6 wk
Abdi et al. 2012           0.4%     -0.01 [-0.17, 0.15]
Hsieh et al. 2011          1.2%     -0.01 [-0.09, 0.08]    2011
Subtotal (95% CI)          1.6%     -0.01 [-0.08, 0.07]
Heterogeneity: [[tau].sup.2] = 0.00; [chi square] = 0.00,
  df = 1 (P = 0.98); [I.sup.2] = 0%
Test for overall effect: Z = 0.24 (P = 0.81)

Total (95% CI)            100.0%    -0.01 [-0.02, 0.00]
Heterogeneity: [[tau].sup.2] = 0.00; [chi square] = 1.74,
  df = 4 (P = 0.78); [I.sup.2] = 0%
Test for overall effect: Z = 1.46 (P = 0.15)
Test for subgroup differences: [chi square] = 0.00,
  df = 1 (P = 0.95), [I.sup.2] = 0%
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Author:Yeh, Tzu-Lin; Chen, Hsin-Hao; Pai, Tsung-Ping; Liu, Shu-Jung; Wu, Shang- Liang; Sun, Fang-Ju; Hwang,
Publication:Evidence - Based Complementary and Alternative Medicine
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2017
Words:10896
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