An Acupoint Catgut-embedding Therapy for Treating Obesity

Summary

Here, we propose a specialized Chinese medicine treatment protocol to manage obesity. This treatment achieves weight loss by implanting absorbable surgical sutures into specific acupuncture points.

Abstract

Obesity is a chronic and complex disease caused by excessive fat deposition, which can lead to multiple complications. It affects individuals of all ages and backgrounds, contributing to a growing public health crisis worldwide. In modern medicine, the available treatments for obesity include drugs, behavioral modifications, and surgical procedures. However, their efficacy is often unsatisfactory and may be accompanied by various side effects. In contrast, Traditional Chinese Medicine offers a wide range of treatment options, including herbal tonics, acupuncture, tuina, acupoint catgut-embedding therapy, and more. Among these, acupoint catgut-embedding therapy has emerged as a popular choice for weight management due to its effectiveness, convenience, affordability, and minimal adverse effects. It involves the insertion of absorbable sutures into acupoints, stimulating the body's natural healing processes and enhancing metabolic function. The gradual absorption of the sutures over time provides a sustained therapeutic effect, allowing for prolonged benefits without the need for continuous treatment sessions. Whether used alone or in conjunction with other therapies, acupoint catgut-embedding therapy exemplifies the benefits of integrative medicine and its potential to empower individuals on their journey toward a healthier lifestyle. Aiming to visualize this ethnic medicine theory and promote its effective inheritance, we detail the acupoint catgut-embedding therapy method for weight loss, covering acupuncture points selection, materials, procedures, and precautions.

Introduction

Obesity is a complex, chronic metabolic disease characterized primarily by an imbalance between energy intake and expenditure, which leads to excessive fat accumulation and abnormal distribution^1.2. Obesity not only affects appearance and quality of life, but it also increases the risk of a number of serious health problems, including diabetes, high blood pressure, heart disease, and certain types of cancer^3,4,5. According to the World Health Organization, the number of obese adults worldwide has more than doubled since 1990. As of 2022, the number of people suffering from obesity globally has exceeded 1 billion, making it one of the major challenges to global public health^2,6.

Currently, the treatment of obesity relies on conventional methods such as behavioral therapies, pharmacotherapy, and surgical interventions. However, these conventional treatments often encounter issues such as poor compliance, significant side effects, and various complications⁷. Therefore, there is an urgent need to explore and develop new treatment options to better meet the needs of patients and improve treatment outcomes. Against this background, an increasing number of clinicians are beginning to adopt complementary and alternative therapies, including Traditional Chinese Medicine, as new options for the treatment of obesity⁸.

Acupuncture, an important component of Traditional Chinese Medicine, has accumulated significant clinical experience in the treatment of obesity in recent years^9,10,11. Among the acupuncture treatments, acupoint catgut-embedding therapy is considered one of the most effective treatments¹². Acupoint catgut-embedding therapy is a therapeutic method that involves implanting catgut or absorbable surgical sutures at selected acupuncture points to provide continuous stimulation. This therapy is easy to perform, has fewer side effects, and can provide long-lasting efficacy. In this way, acupoint catgut-embedding therapy can effectively balance yin and yang, harmonize qi and blood, and regulate the functions of the internal organs, thereby promoting effective weight management and improving overall health¹³. Based on this, acupoint catgut-embedding therapy has become a highly regarded specialty therapy, providing a novel option for the comprehensive treatment of obesity^14,15.

This protocol outlines the operational method of acupoint catgut-embedding therapy for obesity treatment, focusing on patient management, material preparation, selection of acupuncture points, operational steps, and precautions.

Protocol

The clinical trial had been approved by the Ethics Committee of the Hospital of Chengdu University of Traditional Chinese Medicine (NO.2021KL-078). In this study, the diagnostic criteria for simple obesity were defined as a body mass index (BMI) ≥ 28 kg/m², with no other underlying medical conditions contributing to the obesity, in line with the Guideline for Primary Care of Obesity (2019)¹⁶, and the acupoint catgut-embedding operation referred to the Standardized Manipulations of Acupuncture and Moxibustion - Part 10: Thread-embedding Therapy (GB/T21709.10-2008)¹⁷. This study included typical cases of obesity from the Hospital of Chengdu University of Traditional Chinese Medicine. The patients were informed about the study, and their consent was obtained.

1. Pretreatment evaluation

1. Inclusion criteria
   1. Include patients aged 20-50 years, both males and females.
   2. Include patients diagnosed with simple obesity (BMI ≥ 28 kg/m²).
   3. Include patients who are not taking weight-loss drugs or adopting weight-loss measures in the past 3 months.
   4. Include patients who are informed about the treatment and agree to voluntary participation.
      ​NOTE: According to the diagnostic criteria of the Guideline for Primary Care of Obesity (2019)⁶, BMI (weight[kg]/height[m]²) < 18.5 kg/m² indicates low weight, 18.5-24.0 kg/m² indicates normal weight, 24.0-28.0 kg/m² indicates overweight, and ≥ 28.0 kg/m² indicates obesity.
2. Exclusion criteria
   1. Exclude patients with secondary obesity related to genetic, metabolic, or endocrine issues; those whose weight gain is due to specific medications; and individuals with uncontrolled metabolic disorders.
   2. Exclude patients with a history of bariatric surgery.
   3. Exclude patients allergic to acupoint catgut embedding or needle shock.
   4. Exclude pregnant, breastfeeding, or menstruating women, as well as those with mental disorders.
   5. Exclude patients with coagulation disorders, infectious diseases, cardio-cerebrovascular conditions, or other organic diseases and those participating in other clinical trials.
   6. Exclude patients deemed unfit for the trial by the operator due to other factors.
3. Perform a thorough initial patient evaluation that considers the patient's medical history, current medications, and any signs or symptoms that may indicate a potential clotting or infection problem. Conduct coagulation, hematology, and relevant infection tests to rule out related disorders for those with risk factors or pre-existing conditions.

2. Preparation before operation

1. Have the following materials ready: absorbable surgical sutures, band-aid, disposable catgut embedding needles, disposable medical examination gloves, medical absorbent cotton, medical scissors, medical tweezers, povidone-iodine disinfectant, and surgical gauze dressing (Table of Materials and Figure 1).
2. Check package and expiry dates to determine whether the materials are usable. Ensure that all instruments are sterilized.
3. Keep the treating environment clean and dust-free. Keep the temperature comfortable for patients and provide suitable lighting for the operator. Ensure that patient privacy is protected.
   NOTE: Since feelings and habits vary from person to person, the temperature and brightness can be adjusted for personalized comfort.
4. Operator preparation: Wear a neat work uniform. Clean hands according to the hand-washing method for medical staff¹⁸ and wear disposable medical examination gloves
   NOTE: The operator is a licensed acupuncturist or Chinese medicine practitioner who can perform acupoint catgut-embedding operations independently and respond appropriately to any emergencies that may arise during treatment. Do not change the operator during the treatment course.
5. Patient preparation
   1. Instruct the patient to clean the skin surface themselves with mild soap and warm water before each operation to ensure the removal of skin surface contaminants.
   2. Disinfect the acupoints from inside to outside with iodophor cotton balls by the operator before the operation. Repeat the disinfection 2-3 times, ensuring that the diameter of the disinfection area is not less than 5 cm.

3. Operation procedure

1. Position selection
   1. Choose the body position based on the location of the acupuncture points.
   2. Assume a supine position. Expose the location of the acupuncture points.
      NOTE: Avoid choosing positions where the skin is broken, inflamed, or bleeding.
2. Acupuncture point selection
   1. Choose the acupuncture point locations based on the national standard of the People's Republic of China, "Nomenclature and Location of Meridian Points"¹⁹. The following points were selected appropriately: Zhongwan (CV12), Shuifen (CV9), Tianshu (ST25), Guanyuan (CV4), Yinlingquan (SP9), and Fenglong (ST40).
      NOTE: The method of measuring acupuncture points follows the proportional finger-cun system (F-cun), where the patient's finger is used to define the distance. Specifically, the width of the four fingers, with the middle finger's middle joint crease as the reference, equals 3 F-cun (Figure 2).
   2. Zhongwan (CV12): Locate the CV12 point in the upper abdomen, 4 F-cun above the center of the umbilicus, along the anterior midline (Figure 3A).
   3. Shuifen (CV9): Locate the CV9 point in the upper abdomen, 1 F-cun above the center of the umbilicus, along the anterior midline (Figure 3A).
   4. Tianshu (ST25): Locate the ST25 point in the abdomen, horizontal to the center of the umbilicus, 2 F-cun away from the anterior midline (Figure 3A).
   5. Guanyuan (CV4): Locate the CV4 point in the lower abdomen, 3 F-cun down from the center of the umbilicus, along the anterior midline (Figure 3A).
   6. Yinlingquan (SP9): Locate the SP9 point on the medial side of the lower leg, in the depression between the lower border of the medial condyle of the tibia and the medial border of the tibia (Figure 3B).
   7. Fenglong (ST40): Locate the ST40 point on the lateral side of the lower leg, 8 F-cun above the tip of the ankle, at the outer edge of the tibialis anterior muscle, one finger-breadth lateral to Tiaokou (ST38) (Figure 3C).
      NOTE: The selection of the main acupuncture point is usually related to the stomach meridian, spleen meridian, and ren meridian. Other commonly used acupoints include Daheng (SP15), Qihai (CV6), Pishu (BL20), Weishu (BL21), Zusanli (ST36), and Sanyinjiao (SP6).
3. Acupoint catgut-embedding method
   1. Open the package containing the disposable catgut embedding needle and absorbable surgical suture. Take the absorbable surgical suture with sterile tweezers in one hand and the disposable burying needle in the other (Figure 4A).
      NOTE: There is no fixed size of the catgut embedding needle and suture. For needles, it is important that they can accommodate the sutures. For suture size, it is important to ensure that the suture can be completely inserted into the needle. Additionally, their suitability is related to patient tolerance and sensory feedback.
   2. Place the absorbable surgical suture into the tip of the disposable catgut embedding needle using sterile tweezers. Ensure that the suture is flush with the inner edge of the needle tip (Figure 4A).
   3. Fix the acupuncture point with the less dominant hand, and make the skin at the site of needle insertion taut. Hold the needle in the dominant hand, inserting it perpendicular to the skin at the acupuncture point, with an insertion depth of 25 mm (Figure 4B).
   4. Puncture the needle to the desired depth and apply the needling manipulation method until the needling sensation occurs (as long as the patient feels localized soreness and swelling) (Figure 4C, D).
      1. Follow the listed needling manipulation methods (steps 3.3.4.2-3.3.4.3).
      2. Lifting (ti) and thrusting (cha): After the needle is inserted into the acupoint to a certain depth, move the needle up from deep to shallow to lift (ti), and insert the needle from shallow to deep to thrust (cha).
      3. Twirling (nian) and rotating (zhuan): After the needle is inserted into the acupoint, rotate the needle back and forth in the acupoint.
   5. Push the core of the catgut embedding needle while pulling out the needle (Figure 4E). Ensure that the suture remains completely inside the patient. Remove the suture with tweezers and perform a reoperation if it is exposed.
   6. Use sterilized dry cotton balls to apply pressure to the needled skin area to prevent bleeding after removing the needle. Apply a sterile band-aid to help prevent infection (Figure 4F).
   7. Treatment course: One therapy session is given every 3 weeks, and there are two therapy sessions in each course. The treatment will be completed after two consecutive courses.

4. Postoperative care

1. Avoid contact with water in the operating area for 24 h.
2. Maintain a light diet and avoid tobacco, alcohol, seafood, and spicy or stimulating foods.

5. Efficacy assessment

1. Conduct data collection on the day of treatment course initiation and the day of treatment course completion to assess efficacy. Have the same investigator perform the assessments, following established criteria.
   1. Measure the weight before and after treatment to assess patient weight changes. Have the same investigator perform measurements and use the same standard equipment.
   2. Calculate BMI using the formula BMI (kg/m²) = weight (kg)/[height(m)]².
   3. Measure the waist circumference (WC) at the midpoint between the inferior costal margin and the superior border of the iliac crest on the midaxillary line. Avoid compressing soft tissue when measuring. Record the length at the end of the patient's natural respiratory expiration, accurate to 0.1 cm.
   4. Measure the hip circumference (HC) at the horizontal position of the peak of the buttocks, accurate to 0.1 cm.
   5. Calculate the waist-to-hip ratio (WHR): WHR = waist circumference (cm)/hip circumference (cm).
   6. Measure the body fat percentage (BFP) using a body composition analyzer.
      1. The body composition analyzer uses contact electrodes for measurement. After the device enters the measurement state, follow the steps described below.
      2. Remove shoes, socks, and jackets; take off any metal objects on the body; and stand on the analyzer.
      3. Enter the patient's information into the computer. Follow the voice prompts and remain still to complete the measurement.
      4. Hold the handle of the analyzer with both hands, spreading the arms about 30° while keeping the body upright. The entire measurement takes about 2 min during which the patient must remain motionless.

6. Management of adverse events

1. Managing needle shock
   1. Stop the operation and immediately remove the needle if the patient experiences dizziness, nausea, chest tightness, syncope, or any other discomfort.
   2. Lay the patient flat, loosen their clothing, and keep them warm.
   3. Monitor the patient's vital signs at once if the symptoms persistently worsen. Prepare for modern first aid measures (e.g., respiratory support, cardiopulmonary resuscitation, medications like adrenaline and dopamine) and administer them when necessary.
2. Managing pain
   1. Apply a hot compress to relieve mild pain.
   2. Take over-the-counter painkillers (e.g., ibuprofen, acetaminophen) to relieve pain if it does not subside or worsens over time.
   3. Re-evaluate and adjust the treatment strategy (e.g., reduce the size of the suture, change the acupoint, or even attempt other therapies) if the pain continues to exacerbate and the patient cannot tolerate it.
3. Managing inflammatory response
   1. A few days after the operation, the suture may cause mild aseptic inflammation, including redness, swelling, warmth, pain, and occasionally minor exudate. Monitor these symptoms; usually, they do not require treatment.
   2. Treat it as pyogenic inflammation if significant exudate appears. Drain the abscess, disinfect, change dressings, and keep the site clean until it heals. At the same time, use antibiotics under the guidance of a doctor.
4. Managing hematoma
   1. Apply local cold compress immediately to stop bleeding.
   2. Conduct a hot compress to relieve blood stasis.
5. Managing fever
   1. Some patients may experience a rise in temperature to about 38 °C within a few hours after operation, usually without signs of infection. Continue monitoring the patient's condition, as it usually normalizes within 3 days.
   2. Administer physical cooling or oral antipyretics if the high temperature persists.

7. Statistical analysis

1. Collect indicators for assessing efficacy before and after treatment.
2. Use a paired t-test to compare the data collected before and after treatment.
   NOTE: All statistical tests were two-sided; differences were considered statistically significant at P < 0.05.

Results

This study introduces the operational method of acupoint catgut-embedding therapy for patients with obesity. In this study, 20 eligible patients participated and completed the trial. The same diagnostic criteria were applied to all patients. The same acupoint catgut-embedding therapy was performed on all patients by the same operator. Patients' weight, BMI, WC, HC, WHR, and BFP were measured before and after treatment (after the second course).

Discussion

Obesity is a multifactorial disease whose etiology is influenced by the endocrine system, adipocyte function, and inflammatory responses. The arcuate nucleus of the hypothalamus contains a variety of appetite-regulating neurons. These neurons control feeding behavior for the maintenance of whole-body energy balance²⁰. Interactions between insulin, leptin, and thyroid hormones regulate the energy expenditure²¹. Therefore, any factor that leads to neuroendocrine abnormalities...

Materials

Name	Company	Catalog Number	Comments
Absorbable surgical sutures	Hangzhou Aipu Medical Instrument Co., Ltd.	National Medical Device Registration No. 20173023011
Band-aid	Nantong City YOJO Medical Products Co., Ltd.	240801
Body composition analyzer	Beijing Donghuayuan Medical Equipment Co., Ltd.	DBA-510
Disposable catgut embedding needles	Zhenjiang Gaoguan Medical Instrument Co., Ltd.	Jiangsu Medical Device Registration No. 20162201059
Disposable medical examination gloves	Shanghai Kebang Medical Latex Equipment Co., Ltd.	Shanghai Medical Device Registration No. 20192140394
Medical absorbent cotton	Xuzhou Xinjiekang Hygienic Materials Co., Ltd.	Jiangsu Medical Device Registration No. 20172141055
Medical scissors	Zhuji Pengtian Medical Devices Co., Ltd.	Zhejiang Medical Device Registration No. 20232181918
Medical tweezers	Yangzhou Yurun Technology Development Co., Ltd.	Jiangsu Medical Device Registration Certificate No. 20152021351
Povidone-iodine disinfectant	Sichuan Yijieshi Medical Technology Co., Ltd.	230806
Surgical gauze dressing	Shandong Angyang Medical Technology Co., Ltd.	Shandong Medical Device Registration No. 20152140569