YJPDN-02056; No of Pages 7

Journal of Pediatric Nursing xxx (xxxx) xxx

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Journal of Pediatric Nursing

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Effects of auricular acupressure on Korean children who are obese

Hyun Su Cha a,b, Hyojung Park a,⁎
a
Department of Nursing, Sehan University, Yeongam, Republic of Korea
b
College of Nursing, Ewha Womans University, Seoul, Republic of Korea

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: This study aimed to examine the effects of auricular acupresure on reducing obesity in children who are obese.
Received 23 July 2018 Design and methods: The study design was a randomized controlled trial design. Participants aged between 9 and
Revised 19 August 2019 11 years were 65 children who are obese, divided into the experimental group (n = 31) and control group (n =
Accepted 19 August 2019 34). The sessions continued for 8 weeks. The participants in the experimental and control groups received auricular acu-
Available online xxxx
pressure using ear pellets (seeds) on 5 acupoints known to be either effective in obesity treatment or ineffective. Out-
come measures included body image score, children's depression inventory, Rosenberg self-esteem scale, and
Keywords:
Auricular acupressure
anthropometric indices (waist circumference, hip circumference, BMI, etc.).
Obesity Results: Children in the experimental group showed significant improvement in waist circumference and hip circum-
Child ference after 8 weeks compared with those in the control group (p b .001). But no statistically significant difference
in body image score, depression score, or self-esteem score emerged before or after auricular acupressure in the exper-
imental and control groups.
Conclusions: Auricular acupressure using ear pellets for eight weeks was effective in decreasing waist and hip circum-
ferences in children who are obese.
Practice implications: Auricular acupressure can be used as an intervention method for children to control obesity.
© 2019 Elsevier Inc. All rights reserved.

The prevalence of obesity is rapidly increasing worldwide. Specifi-
cally, in Korea, the childhood obesity rate among elementary, middle,
and high school students increased from 11.2% to 16.5% between 2008
and 2016 (The Education Ministry, 2016), making it a serious social
problem. Childhood obesity accounts for 80% of adult rates of the dis-
ease (Noh, 2012), and among obese adults, previous childhood obesity
aligns with a higher risk of cardiovascular disease (Freedman et al.,
2004; Goran, 2001). In addition, childhood obesity is more serious, as
it results in higher extreme obesity than that of adults who already
have the condition (Kim & Park, 1995). A decrease in childhood obesity
is likely to lead to a decrease in the disease, which, in turn, may lead to a
reduction in adult illnesses in the next 30 to 40 years. Thus, it is impor-
tant to manage when children have the disease childhood obesity.
Obesity induces chronic diseases with an increased possibility of
triggering risk factors for cardiovascular disease like hypertension and
complications such as hyperlipidemia and diabetes mellitus
(Freedman, Dietz, Srinivasan, & Berenson, 1999). Obese people have a
poorer body image, which can lead to anxiety, depression, and dietary
disorders (Pila, Sabiston, Brunet, Castonguay, & O'Loughlin, 2015). Be-
cause obesity decreases self-esteem, children who are obese have
⁎ Corresponding author at: College of Nursing, Ewha Womans University, 52
Ewhayeodae-gil, Seodaemoon-gu, Seoul 03760, Republic of Korea.
E-mail address: hyojungp@ewha.ac.kr (H. Park).
lower societal adaptability and less social confidence than their peers
(Banis et al., 1988).
Childhood obesity is defined as a body mass index (BMI) at or above
the 95th percentile for children and teens of the same age, and sex and a
BMI exceeding the cut-off value, which is 25 kg/m2 in the Asia-Pacific
region, regardless of percentile. For assessment of childhood obesity, na-
tional growth charts are used, and in Korea, the 2007 Korean National
Growth Chart for Korean children and adolescents is used (Moon
et al., 2008).
Treatment of childhood obesity is typically achieved through diet,
behavior modification, and exercise. The difference from treatment for
adult obesity is in the growing phase, so by keeping the body weight sta-
ble, BMI decreases as height increases, treating obesity as a conse-
quence. In other words, calorie intake should be reduced while
sufficiently supplying the nutrition needed for growth and develop-
ment. Since children who are obese are more interested in weight loss
compared to children with normal weight, they have a higher rate of
weight loss attempts and try more diverse ways in which to lose weight
(Song & Park, 2010). Because of such characteristics of children who are
obese, they desire to undergo auricular therapy.
As the number of dual-income couples increases, so does the
amount of quality time parents spend with their children decreases.
As a result, treatment for children who are obese is becoming increas-
ingly difficult. Auricular acupressure, which can be performed by school

https://doi.org/10.1016/j.pedn.2019.08.016
0882-5963/© 2019 Elsevier Inc. All rights reserved.

Please cite this article as: H.S. Cha and H. Park, Effects of auricular acupressure on Korean children who are obese, Journal of Pediatric Nursing,
https://doi.org/10.1016/j.pedn.2019.08.016
2 H.S. Cha, H. Park / Journal of Pediatric Nursing xxx (xxxx) xxx
health teachers or community nurses, is an effective intervention
method for reducing childhood obesity.
The idea of auricular acupressure originates from the assumption
that ears are a miniature representation of the human body, so a disease
occurring in the internal organs of the human body may be reflected in
the acupoints spread throughout the ears. Based on this idea, acupoints
were recognized as part of disease treatment, supporting auricular acu-
puncture, in 1990 by the World Health Organization (WHO). Auricular
acupuncture treats diseases by applying acupuncture on corresponding
acupoints, whereas auricular acupressure attaches magnet beads or
small plant seeds, to acupoints and stimulates them by applying pres-
sure to treat a disease. Due to pain and fear of intervention, auricular
acupuncture is difficult to use on children, resulting in economic and
health related hardship. However, auricular acupressure is an econom-
ically feasible alternative and can be easily applied to children; there-
fore, it is suitable for a study that intends to improve child obesity.
Because auricular acupressure and auricular acupuncture have the
same working mechanism (Noigier, 1981), the effect is the same. In
the case of auricular acupuncture, stimulation is introduced at the auric-
ular reflex points by using acupuncture needles; as a result, the effects of
treatment are felt throughout the whole body. The effect of auricular
acupuncture on obesity is to burn fat accumulated in the body (Vettor
et al., 1993) and to suppress appetite (Gong et al., 2012; Sherwood,
2011). Also, the mechanism for enhancing lipid metabolism decreases
the level of blood lipid by increasing the β-endorphin level in plasma
through the central nervous system (Vettor et al., 1993). The mecha-
nism of appetite suppression increases the ratio of leptin-receptor bind-
ing in the hypothalamus and reduces leptin in the blood by reducing the
leptin resistance shown in obese patients (Gong et al., 2012). Moreover,
auricular acupuncture suppresses appetite by increasing the appetite-
suppressing peptide hormone. Leptin is a substance that inhibits appe-
tite and, in obese patients, is higher than normal; however, their leptin
resistance, which does not function properly, is increased (Sherwood,
2011). In contrast, auricular acupuncture increases blood leptin and re-
duces leptin resistance in obese patients.
A study conducted using a single group, without a control group
(Youn, Kim, & Lee, 2005), assessed the effects of auricular acupressure
on child obesity. This study measured the effects of auricular acupressure
based on changes made in the Broca index without measuring anthropo-
metric indices. Also, another study failed to verify the single effect of au-
ricular acupressure, only assessing the combined effects of exercise and
auricular acupressure using a single-group study design (Kwak, Kim, &
Byun, 2009). Researchers have conducted studies on obese adolescents
aged 18 to 20 years old (Hsieh, 2010) and children who are obese (Kim,
Ham, Kang, & Jun, 2014). Nonetheless, few recent studies have attempted
to examine the effects of auricular acupressure on children. Therefore, this
study provides basic data using complementary and alternative therapy
as a nursing intervention in the management of childhood obesity by
assessing the effects of auricular acupressure in obese children, based on
a randomized control group and anthropometric indices. The purpose of
this study was to examine the effects of auricular acupressure on the pri-
mary outcome of reducing obesity in children and secondary psychologi-
cal outcomes. The hypotheses for this study follow:
Hypothesis 1. The anthropometric indices measured using the body
measurement machine (body fat mass, percentage body fat, body water,
protein, mineral, weight, BMI, waist measurement, hip circumference,
waist-hip ratio) of the experimental group with 8 weeks of auricular acu-
pressure will improve compared to the placebo control group.
Hypothesis 2. The body image scores measured using the structured
questionnaire of the experimental group with 8 weeks of auricular acu-
pressure will increase compared to the placebo control group.
Hypothesis 3. The depression scores measured using the structured
questionnaire of the experimental group with 8 weeks of auricular acu-
pressure will decrease compared to the placebo control group.
Please cite this article as: H.S. Cha and H. Park, Effects of auricular acupressure on Korean children who are obese, Journal of Pediatric Nursing,
https://doi.org/10.1016/j.pedn.2019.08.016
Hypothesis 4. The self-esteem scores measured using the structured
questionnaire of the experimental group with 8 weeks of auricular acu-
pressure will increase compared to the placebo control group.
Method
Design
This study was a randomized controlled trial to examine the effects
of auricular acupressure on obesity improvement in children who are
obese.
Sample
We selected participants for the experimental and control groups
between March and July of 2017. Participants aged from 9 to 11 years
old were students at two elementary schools and active in any of 12
local children's centers in Seoul. We selected potential participants
using the following criteria: 1) Those who were willing to voluntarily
participate in the study and obtained the caregivers' consent on study
participation after listening to the study description; 2) Those whose
BMI exceeded 25 kg/m2 or a BMI which was at or above the 95th per-
centile for children of the same age and sex; 3) Those without inflam-
mation or wounds in their ears; 4) Those who had not received other
treatments or surgeries in the prior 6 months; 5) Those who did not
have any skin diseases, such as: allergies, atopic dermatitis, or urticaria;
6) Those who had no prior history of endocrine diseases (pituitary dis-
orders, thyroid disorders) or mental disorders; 7) Those who could par-
ticipate in auricular acupressure for 8 weeks; and 8) Those who did not
receive prior treatment such as pharmacotherapy or surgery during the
study period.
We calculated the sample size based on the Cohen (1988) power-
analysis method. In a previous study that assessed the effects of auricu-
lar acupressure in obese high school students, the number of partici-
pants was calculated to be 26 people for each of the experimental and
control groups by having 0.70 for the effect size, 0.15 for the significance
level, and 0.80 for the power (Kim et al., 2014). Considering there was a
26% dropout rate, data was gathered from 35 people each for the exper-
imental and control groups. Of children who qualified based on the
participant-selection criteria, we selected and divided 70 children into
the experimental and control groups. The experimental group had a
total of four participants who dropped out of the study due to personal
reasons (two people), transferred to another school (one person), or
had no interest in auricular acupressure (one person). In the control
group, a participant dropped out of the study for personal reasons.
Therefore, the study had a total of 65 participants: 31 in the experimen-
tal and 34 in the control group (Fig. 1).
On the basis of previous studies (Hsieh, 2010) on auricular acupres-
sure, we placed ear pellets (seeds) on a participant's ear once a week, al-
ternating ears each time, and then replaced these pellets, while
confirming their positions. We instructed participants to lightly press
the pellet-applied sites before eating three times a day or whenever
they felt hungry. Likewise, we performed auricular acupressure once a
week with each person a total of eight times. For the selection of auric-
ular acupoints where the pellets were placed, we selected the five
acupoints known to be effective in obesity treatment as determined
by the WHO (Romoli, 2010). In the control group, we selected five
acupoints that were known to be ineffective in obesity treatment, ac-
cording to the WHO standard (Romoli, 2010). After wiping off foreign
matter in the ears with an alcohol pad, we applied the pellets to the
hunger, endocrine, spleen, Shenmen, and the stomach zones for the ex-
perimental group, while applying the pellets to the knee, hip-joint, lum-
bar, thoracic, and tooth zones respectively for the control group (Fig. 2).
We pressed the pellets to the auricular acupoints 10 times an intervals
of 2 s for a period of 5 min using a thumb and an index finger, eliciting
 H.S. Cha, H. Park / Journal of Pediatric Nursing xxx (xxxx) xxx 3

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Fig. 1. CONSORT flow diagram for the study.

minor pain. To prevent exercise and meals from being factored in as
confounding variables, we asked participants not to initiate any new ex-
ercise routines and to stick to three meals a day.
Measures
Data on participants' demographic characteristics consisted of ques-
tions about age, school year, health status, regular meals, regular exer-
cise, illness, medication, family history of obesity, and economic status.
We measured height with a height measure (HM202, Phoenix,
Korea) and measured body weight, BMI, skeletal muscle mass, fat
mass, body fat percentage, body water, protein, and minerals with
InBody (InBody 270, Biospacr Co., Ltd., Korea). We measured waist
and hip circumferences with a tape measure.
We used the Body-Esteem Scale developed by Mendelson and White
(1982) and revised and supplemented by Cho (1992) to examine partic-
ipants' satisfaction in their body image in relation to obesity. A total of
12 questions comprised on a 4-point scale, with a total score ranging

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Fig. 2. Schematic diagram of the auricular acupressure points stimulated.

Please cite this article as: H.S. Cha and H. Park, Effects of auricular acupressure on Korean children who are obese, Journal of Pediatric Nursing,
https://doi.org/10.1016/j.pedn.2019.08.016
4 H.S. Cha, H. Park / Journal of Pediatric Nursing xxx (xxxx) xxx

from 12 to 48 points. Higher scores indicated a more positive body instruments and applied sham auricular acupressure to acupoints that
image. Cronbach's α at the development of this instrument was 0.85, did not relate to obesity treatment for 8 weeks, the same period as the
and that of the study conducted by Cho (1992) was 0.70. In this study, experimental group
the Cronbach's α was 0.75. We checked on and encouraged participants by telephone and text
To measure childhood depression associated with obesity, the Ko- to determine whether the pellets were securely attached and that the
rean version of the CDI, developed by Kovac and translated into Korean, pellet-applied sites were being pressed as instructed.
was standardized by Cho and Lee (1990). CDI is a self-reporting scale To analyze the effects of auricular acupressure after 8 weeks, we
developed to assess the cognitive, emotional, and behavioral symptoms asked the experimental and control groups to answer a questionnaire
of pediatric depression. The CDI is a modified version of Beck's Depres- and reexamine participants' anthropometric assessment. We then com-
sion Inventory (1967) for children (aged 8–13 years) and structured to pared and analyzed the results.
evaluate participants' state (state is the same as mood so you don't need
to say “mood state”) for the previous 2 weeks in a self-reporting form. Data analysis
We scored a total of 27 items from 0 to 2 points for each question, and
the total score was distributed from 0 to 54 points. A study conducted We analyzed the collected data using SPSS WIN 21.0. We reviewed
by Kim, Yang, Chung, Hong, and Kim (2005) focused on the notion in detail the homogeneity of the two groups by independent t-test
that expression of depressive symptoms might vary according to devel- and chi-square test. We analyzed differences between the two groups
opmental level, and analysis of children's depression factor was found to before and after the experiment by independent t-test and Mann–
be suitable for use with Korean children. The Cronbach's α of the study Whitney U test, whereas we implemented the paired t-test and
conducted by Cho and Lee (1990) was 0.82, and that of this study was Wilcoxon Signed-Rank Test to assess changes before and after the ex-
0.97. periment between the two groups.
We used the instrument developed by Rosenberg (1965) and trans-
lated by Lee (1996) for assessment of self-esteem. The scale consisted of Results
a total of 10 questions and has been widely used for children and adults.
This 4-point scale inversely converted negative sentences (questions 3, In terms of the Homogeneity test of the experimental and control
5, 8, 9, and 10). The scores ranged from 10 to 40 points, and higher groups, no statistically significant differences emerged between the ex-
scores indicated higher self-esteem. In the Lee study, the Cronbach's α perimental and control groups (see Table 1) on body image, children's
was 0.79, and that of this study was 0.84. depression, self-esteem, and anthropometric indices (see Table 2).
Therefore, the groups were homogeneous.
Data-collection procedure Waist circumference decreased in the experimental group, whereas
that of the control group increased. The differences between the exper-
After obtaining approval from the principals of two elementary imental and control groups after the intervention was statistically sig-
schools and 12 local children centers in Seoul, Korea, we posted a public nificant (t = 3.79, p b .001). Hip circumference also decreased in the
notice for study participation and invited participants who met the se- experimental group while it increased in the control group. The differ-
lection criteria to join the study. ence between the experimental and control groups after the
The research supervisor and co researcher visited the schools and
local children's centers of participants and explained the purpose of Table 1
the study to all the participants recruited. Then, we sent the study de- Homogeneity test of general characteristics between the two groups (N = 65).
scription and written consent to the legal representatives of the partic-
Characteristics Classification Exp. Con. χ2 p
ipants and obtained consents. (n = 31) (n = 34) or t
After obtaining consent from the legal representatives, we measured
n (%) or n (%) or
variables through a series of questionnaire and anthropometric mea- M ± SD M ± SD
surements. We measured height with an automatic height scale in the
Age (yr) 10.5 ± 0.99 10.4 ± 0.95 0.81 .421
health offices of the schools. In cases when the heights measured before
Grade Fourth 8 (25.8) 12 (35.3) 0.87 .649
and after the study differed or when height was measured to be shorter Fifth 8 (25.8) 9 (260)
than the premeasured one, we measured height twice and used the Sixth 15 (48.4) 13 (38.2)
mean value. We measured waist circumference according to WHO State of health Excellent 6 (19.4) 7 (20.6) 4.13 .389
criteria around the abdominal area, between the lowest rib and the Good 11 (35.5) 7 (20.6)
Average 10 (32.3) 12 (35.3)
crista iliaca in the upright posture wherein the participant exhaled com- Fair 2 (6.5) 7 (20.6)
fortably. For the measurement of hip circumference, we measured the Poor 2 (6.5) 1 (2.9)
most protruding area of the hip. We calculated the ratio of waist-to- Regular meals Yes 22 (71.0) 16 (47.1) 3.82 .051
hip circumference using the waist–hip circumference. To reduce any No 9 (29.0) 18 (52.9)
Regular Yes 20 (64.5) 16 (47.1) 2.00 .157
measurement error, the same person took the measurements using
exercise No 11 (35.5) 18 (52.9)
the same measuring instruments and methods. Exercise 4.50 ± 4.00 ± 0.72 .475
For the 31 randomly selected elementary school students who are (times/week) 2.115 2.000
obese (experimental group), we visited the schools once a week and at- Disease Presence 3 (9.7) 5 (14.7) 0.32 .570
tached and replaced the pellets (seeds) on participants, investing 5 min Absence 28 (90.3) 29 (85.3)
Type of disease 1. Skin disease 0 3 2.88 .090
per student while addressing the pellet-applied sites. We instructed 2. Pulmonary disease
participants to lightly press the pellet-applied sites before and after 3 2
(cold, rhinitis, asthma)
their daily three meals and every time they felt hungry. Likewise, we Using drug Yes 4 (12.9) 4 (11.8) 0.02 .889
performed auricular acupressure a total of eight times, once a week No 27 (87.1) 30 (88.2)
Type of drug 1. Skin disease 0 1
per person. The auricular acupressure-applied sites were the hunger,
2. Pulmonary disease
Shenmen, stomach, endocrine, and spleen zone, and these sites are 3 3
(rhinitis, asthma)
known to be effective in obesity treatment among auricular acupoints 3. Herbal medicine 1 0
specified by WHO Economic 1. Good 4 (12.9) 1 (2.9) 3.50 .174
For the 34 randomly selected obese elementary school students status 2. Average 26 (83.9) 33 (97.1)
3. Bad 1 (3.2) 0 (0)
(control group), we conducted a preexamination using the same

Please cite this article as: H.S. Cha and H. Park, Effects of auricular acupressure on Korean children who are obese, Journal of Pediatric Nursing,
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 H.S. Cha, H. Park / Journal of Pediatric Nursing xxx (xxxx) xxx 5

Table 2 Discussion
Homogeneity test of study variables (N = 65).

Variable Scale Exp. Con. χ2 or t p This study attempted to verify whether auricular acupressure is ef-
(n = 31) (n = 34) fective with children who are obese as an obesity treatment. Because
n (%) or M ± SD n (%) or M ± SD few researchers have applied auricular acupressure to children to de-
crease obesity, in this study we compared and examined previous stud-
Height kg 150.31 ± 7.64 149.07 ± 9.63 0.57 .572
Body weight kg/m2 59.85 ± 8.49 60.94 ± 9.81 −0.48 .634 ies that applied auricular acupressure and auricular acupuncture with
Body mass index kg 26.42 ± 2.67 27.26 ± 1.91 −1.48 .145 adults.
Skeletal muscle mass kg 19.81 ± 3.45 19.65 ± 4.31 0.17 .868 Following auricular acupressure, a statistically significant difference
Body fat mass % 23.04 ± 4.34 24.45 ± 3.76 −1.41 .165 emerged between the experimental and control groups as waist cir-
Percentage body fat L 38.50 ± 4.61 40.36 ± 4.10 −1.73 .089
Body water kg 26.99 ± 4.28 26.73 ± 5.35 0.21 .832
cumference decreased in the experimental group and increased in the
Protein kg 7.21 ± 1.14 7.17 ± 1.42 0.12 .904 control group (t = 3.79, p b .001). This result was consistent with a pre-
Mineral cm 2.60 ± 0.44 2.59 ± 0.58 0.09 .927 vious study (Hsieh, Su, Fang, & Chou, 2012) in which auricular acupunc-
Waist circumference cm 88.68 ± 5.84 89.87 ± 5.02 −0.88 .381 ture reduced waist circumference. The mechanism by which auricular
Hip circumference 95.16 ± 5.92 94.14 ± 5.33 0.74 .465
acupuncture reduced obesity was the suppression of appetite through
Waist-hip ratio 0.93 ± 0.05 0.96 ± 0.04 −1.89 .063
Depression 7.97 ± 8.85 11.38 ± 9.74 −1.45 .151 the reduction of leptin resistance (Gong et al., 2012; Sherwood, 2011).
Body image 30.81 ± 4.87 30.29 ± 5.71 0.39 .700 Leptin is a modulator that controls body weight by suppressing appetite
Self-esteem 30.71 ± 5.64 30.32 ± 4.96 0.29 .770 using the hormone secreted from white adipose tissue (Zhang et al.,
1994). Leptin resistance occurs in obese patients, resulting in an im-
proper response of the leptin receptor in the brain even when the leptin
concentration increases in the blood. Therefore, the brain of an obese
experiment was statistically significant (t = 4.13, p b .001). Body fat patient does not detect leptin, a signal that lowers appetite, until the
mass, percentage of body fat, body water, protein, minerals, weight, leptin concentration in the blood reaches a higher level (Sherwood,
BMI, and waist–hip ratio showed no statistically significant difference 2011). Auricular acupuncture and auricular acupressure increase the
between the experimental and control groups before and after auricular combining ratio, as well as the action of leptin receptors, by reducing
acupressure. Therefore, Hypothesis 1 was partially supported (Table 3). leptin resistance in obese patients. Once the action of the leptin receptor
No statistically significant difference in body image score emerged is increased, it reduces appetite and body fat, resulting in weight loss
before and after auricular acupressure was utilized in the experimental (Gong et al., 2012).
and control groups. Therefore, Hypothesis 2 was not supported. Auricular acupuncture and auricular acupressure work the same
No statistically significant difference emerged in the depression way in Western medicine as appetite suppressants but have no side ef-
scores before and after auricular acupressure in the experimental and fects. Anorectic agents cannot be prescribed to children who are obese,
control groups. Therefore, Hypothesis 3 was not supported. but auricular acupuncture and auricular acupressure can be applied to
No statistically significant difference emerged in self-esteem scores them. The mechanism by which auricular acupuncture reduces waist
before and after auricular acupressure in the experimental and control circumference is by burning fat accumulated in the body (Vettor et al.,
groups. Therefore, Hypothesis 4 was not supported. 1993). The mechanism of lipid metabolism enhancement decreases

Table 3
Comparison of variables between the experimental and control groups (N = 65).

Variable Group Pre test Post test Within group Mean difference Between groups

M ± SD M ± SD t p M ± SD t p

Height Exp. (n = 31) 150.31 ± 7.64 151.78 ± 7.65 −5.72 b.001 −1.48 ± 1.44 −1.00 .320
Con. (n = 34) 149.07 ± 9.63 150.25 ± 9.50 −7.44 b.001 −1.17 ± 0.92
Body weight Exp. (n = 31) 59.85 ± 8.49 60.53 ± 8.72 −2.43 .021 −0.69 ± 1.57 1.27 .207
Con. (n = 34) 60.94 ± 9.81 62.11 ± 9.66 −4.64 b.001 −1.17 ± 1.47
Body mass index Exp. (n = 31) 26.42 ± 2.66 26.21 ± 2.78 1.37 .181 0.21 ± 0.85 1.68 .099
Con. (n = 34) 27.26 ± 1.91 27.36 ± 1.88 −0.97 .339 −0.10 ± 0.62
Skeletal muscle mass Exp. (n = 31) 19.81 ± 3.45 20.56 ± 3.36 −6.04 b.001 −0.75 ± 0.70 0.57 .568
Con. (n = 34) 19.65 ± 4.35 20.50 ± 4.47 −7.30 b.001 −0.85 ± 0.68
Body fat mass Exp. (n = 31) 23.04 ± 4.34 22.43 ± 4.90 2.19 .036 0.61 ± 1.54 0.93 .357
Con. (n = 34) 24.45 ± 3.76 24.17 ± 3.76 1.25 .219 0.28 ± 1.30
Percentage body fat Exp. (n = 31) 38.50 ± 4.61 36.94 ± 4.89 4.53 b.001 1.56 ± 1.91 0.94 .350
Con. (n = 34) 40.36 ± 4.10 39.23 ± 4.51 3.75 .001 1.13 ± 1.76
Body water Exp. (n = 31) 26.99 ± 4.28 27.93 ± 4.21 −6.15 b.001 −0.94 ± 0.85 0.64 .525
Con. (n = 34) 26.73 ± 5.35 27.81 ± 5.55 −7.10 b.001 −1.08 ± 0.88
Protein Exp. (n = 31) 7.21 ± 1.14 7.47 ± 1.12 −5.64 b.001 −0.25 ± 0.25 0.49 .626
Con. (n = 34) 7.17 ± 1.42 7.46 ± 1.47 −6.69 b.001 −0.29 ± 0.25
Mineral Exp. (n = 31) 2.60 ± 0.44 2.70 ± 0.44 −5.15 b.001 −0.10 ± 0.11 −0.76 .452
Con. (n = 34) 2.59 ± 0.58 2.67 ± 0.59 −4.31 b.001 −0.08 ± 0.11
Waist circumference Exp. (n = 31) 88.68 ± 5.84 87.44 ± 5.67 2.34 .026 1.24 ± 2.95 3.79 b.001
Con. (n = 34) 89.87 ± 5.02 92.01 ± 5.08 −3.06 .004 −2.15 ± 4.09
Hip circumference Exp. (n = 31) 95.16 ± 5.92 94.42 ± 6.35 1.44 .161 0.74 ± 2.87 4.13 b.001
Con. (n = 34) 94.14 ± 5.33 96.00 ± 5.75 −5.11 b.001 −1.86 ± 2.13
Depression Exp. (n = 31) 7.97 ± 8.85 8.48 ± 11.48 −0.29 .773 −0.52 ± 9.87 −1.085 .282
Con. (n = 34) 11.38 ± 9.74 9.68 ± 12.10 1.55 .132 1.71 ± 6.44
Body image Exp. (n = 31) 30.81 ± 4.88 30.19 ± 5.19 0.77 .445 0.61 ± 4.41 0.97 .333
Con. (n = 34) 30.29 ± 5.71 30.94 ± 4.95 0.65 .522 −0.65 ± 5.84
Self-esteem Exp. (n = 31) 30.71 ± 5.64 29.97 ± 6.14 0.79 .434 0.74 ± 5.21 0.56 .580
Con. (n = 34) 30.32 ± 4.959 30.35 ± 5.84 −0.03 .977 −0.03 ± 5.92

Please cite this article as: H.S. Cha and H. Park, Effects of auricular acupressure on Korean children who are obese, Journal of Pediatric Nursing,
https://doi.org/10.1016/j.pedn.2019.08.016
6 H.S. Cha, H. Park / Journal of Pediatric Nursing xxx (xxxx) xxx
blood lipid levels by increasing β-endorphin level in plasma through the
central nervous system (Vettor et al., 1993).
Following auricular acupressure, a statistically significant difference
emerged between the experimental and control groups as hip circum-
ference decreased in the experimental group and increased in the con-
trol group (t = 4.13, p b .001). This result is consistent with a previous
study (Hsieh, 2010) in which auricular acupuncture reduced hip cir-
cumference. The hip of a child with obesity is the region where body
fat is distributed much like that of the waist. The mechanism of decreas-
ing the hip circumference is considered to be the same as the mecha-
nism of decreasing the waist circumference mentioned above.
Eight weeks of auricular acupressure seemed to be effective in de-
creasing childhood obesity by decreasing waist circumference and hip
circumference in children who are obese. A period of eight weeks was
chosen for this study in the application of auricular therapy. This dura-
tion was enough to produce the weight loss effect, and it also coincided
with the findings obtained in previous studies (Abdi et al., 2012; Hsieh
et al., 2012; Hsu et al., 2005; Hsu, Hwang, Chao, Chang, & Chou, 2005).
Abdominal obesity increases the incidence of cardiovascular disease
(Keihani et al., 2015). Decreased waist circumference can reduce the in-
cidence of cardiovascular disease. Because the risk of cardiovascular dis-
ease increases if a person has been obese from childhood, it is important
to manage waist circumference to reduce the risk of cardiovascular dis-
ease (Freedman et al., 2004; Goran, 2001). It is notable that auricular
acupressure, which reduces waist circumference in children who are
obese, will have the effect of reducing cardiovascular disease caused
by adult obesity in the future.
In this study, there were no signs of side effects. The parents of the
children who are obese who participated in the experiment were not
concerned and did not ask questions about the experiment, indicating
that auricular acupressure is an effective nursing intervention program
for children who are obese. Auricular acupressure is considered to be a
safer, more effective, and cost-effective treatment for childhood obesity
compared to pharmacotherapy, surgery, and therapy. The results sup-
ported the hypothesis that auricular acupressure may be used as a pri-
mary intervention to reduce obesity among obese children. After
receiving education on auricular acupressure, school health teachers
or community nurses can provide auricular therapy to obese children
in schools or local communities. School and community-based nurses
can use auricular acupressure for children in the community settings.
In addition, further study is needed to identify the effects of other pa-
rameters such as BMI, weight, and body-fat mass, by long-term auricu-
lar acupressure and large sample size. Further study is needed to
identify the effects of auricular acupressure on secondary psychological
outcomes. This present study result was inconsistent with a previous
study (Nourshahi, Ahmadizad, Nikbakht, Heidarnia, & Ernst, 2009) in
which auricular acupressure and auricular acupuncture reduc27.9
∼ 29.9 kg/m2, which was much higher than the mean BMI of the exper-
imental and control groups in this study, with 26.42 ± 2.67 kg/m2 and
26.42 ± 2.67 kg/m2, respectively. In the auricular acupuncture designed
for obesity reduction in this study, the effects of auricular acupuncture
were shown to be greater, along with more significant obesity
(Shiraishi, Onoe, Kojima, Sameshima, & Kageyama, 1995). Therefore,
participants in previous studies whose mean BMI was much greater
showed body-fat mass reduction. However, the effect of body fat mass
reduction was not observed in participants with low BMI in this study.
The number of children who are obese in the United States is higher
than that in Korea (Choi, 2015). One small study applied auricular ther-
apy to obese children in the United States and found that the effect of
auricular therapy was greater when the degree of obesity was higher
(Shiraishi et al., 1995); therefore, it is expected that the BMI of children
who are obese will be reduced if auricular therapy is applied.
BMI, measured after providing auricular acupressure, was not signif-
icantly decreased in the experimental group compared with the control
group. This result was inconsistent with the results of a previous study
(Kim et al., 2014) in which auricular acupressure reduced BMI. Previous
Please cite this article as: H.S. Cha and H. Park, Effects of auricular acupressure on Korean children who are obese, Journal of Pediatric Nursing,
https://doi.org/10.1016/j.pedn.2019.08.016
researchers reflected changes in BMI only by fluctuations in body fat
and muscle mass. However, in this study, changes in BMI were due to
growth in skeletal thickness as well as changes in body fat and muscle
mass. In this study, BMI may have decreased due to a decrease in body
fat and muscle mass, and it may have increased due to growth of skele-
tal thickness that occurred simultaneously, resulting is no change in
BMI. Furthermore, the fact that auricular acupressure reduced waist cir-
cumference without decreasing BMI is considered to be a superior
method of treating childhood obesity. Adults may aim to lower their
weight to a more normal size as a treatment for obesity. Because chil-
dren are in a growth phase, however, the goal of obesity treatment is
to increase height significantly, gradually increase body weight, and re-
duce body fat.
Limitations
This study has several limitations. First, the generalization of these
study results to the whole population requires attention because of
small sample sizes. Second, the muscles and skeletons of growing chil-
dren develop at a rapid pace. Last, it is necessary to use caution when
interpreting results because factors such as eating habits, exercise, and
lifestyle, were not controlled. Body fat mass following auricular acupres-
sure did not show a statistically significant decrease in the experimental
group compared to the control group.
Conclusion
The purpose of this study was to investigate the effects of auricular
acupressure on childhood obesity. Results showed that auricular acu-
pressure was effective in decreasing the waist and hip circumferences
of participants. Based on the results and discussion in this study, we sug-
gest the following: First, a study with a greater number of participants
should be conducted because the number of participants was low in
this study, the results may not apply to all children who are obese. Sec-
ond, a study with an increased duration of auricular-acupressure appli-
cation should be conducted because the duration of auricular
acupressure was brief in this study that its benefits may not have been
obtained. Third, a follow-up study on the effects on waist measurement
and abdominal-circumference reduction some time following auricular
acupressure should be conducted. Fourth, further study targeting highly
children who are obese should be conducted, as the effects of auricular
acupressure may not appear due to the low obese level of participants in
this study.
CRediT authorship contribution statement
Hyun Su Cha: Writing - original draft. Hyojung Park: Investigation,
Supervision, Conceptualization, Methodology, Data curation, Writing -
original draft, Writing - review & editing.
Acknowledgments
This work was supported by the National Research Foundation of
Korea (NRF) grant funded by the Korea government (MSIT)
(2014R1A3049445).
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