Study design
This single-center, randomized, sham-controlled will be conducted at Shenzhen Traditional Chinese Medicine Hospital (Shenzhen, China). The study protocol was approved by the Ethics Committee on Shenzhen Traditional Chinese Medicine Hospital, and conducted in accordance with the 1975 Declaration of Helsinki. The flowchart of the research procedure is shown in Fig. 1.
Patients’ recruitment procedure
Patients who meet the inclusion criteria will be mainly recruited through outpatient clinics, online or offline advertisements (e.g., newspaper, poster, websites), or WeChat public account of Shenzhen Traditional Chinese Medicine Hospital. If a patient is interested in joining the study, he/she can contact and consult with one of the researchers. Those patients who meet the inclusion criteria will be involved in the study. All the participants will sign the written informed consent form prior to start of the study. The schedule of patients’ enrolment, intervention, and assessments is illustrated in Fig. 2.
Inclusion criteria
Inclusion criteria are as follows:
(1) Diagnosed with obesity referred to Asian adult BMI criteria defined and proposed by the WHO Western Pacific region obesity working group in 2000;
(2) WC of male ≥ 90 cm, or WC of female ≥ 80 cm;
(3) Aged 18 to 65 years old;
(4) Without the taboo of catgut embedding therapy;
(5) Written informed consent.
Exclusion criteria
Patients with any one of the following criteria are excluded from this trial:
(1) With endocrine diseases (thyroid disease, pituitary disease, and diabetes mellitus) and autoimmune disease (systemic lupus erythematosus, Sjogren’s syndrome, and rheumatoid arthritis);
(2) With metabolic diseases such as hypertension and dyslipidemia;
(3) Other methods are being used to control body mass and abdominal circumference, such as surgery, drugs, etc;
(4) Women in pregnancy, nursing, perimenopause
(5) With some severe diseases of the heart, liver, kidney, or tumor;;
(6) Diagnosed with a psychiatric disorder;
(7) Participated in other studies within 3 months.
Dropout criteria
(1) Patients who do not meet the inclusion criteria, while are mistakenly enrolled;
(2) Occurrence of severe AEs or complications, which are resulted in stopping the trial.
Sample size
The sample size is calculated on the basis of results of a previous clinical trial [19]. The primary effective parameter in the present study is BMI from baseline to the treatment after 2 months. According to a previous study [19], in the ACE group, the BMI decreased 1.65 and the standard deviation (SD) was 1.24; besides, in sham ACE group, the BMI reduced 0.38 and the SD was 1.51. Considering a two-sided significant level of 0.05 and a power of 0.90, 26 participants in each group are required which is calculated by t test in G*Power software (Version 3, Institute for Experimental Psychology, Heinrich-Heine-University, Germany). A dropout rate of 15% was taken into account, and a total of 99 participants are recruited in this trial (n = 33 participants per each group).
Randomization and allocation concealment
If the participants meet all the inclusion criteria and sign the written informed consent form, they ask to accept the principle of random allocation. Hence, 99 eligible participants wil be randomly assigned to verum ACE group, sham ACE group, and waiting-list (WL) group at a ratio of 1:1:1. A random allocation sequence number will be generated with the Statistical Analysis System software (SAS, version 9.1.3, SAS Institute Inc., Cary, NC, USA) by an independent statistician, who will be not involved in the treatment or data collection. The sequential numbers are written on cards and sealed in an opaque envelope by an independent research assistant. After a participant randomly selects an opaque envelope and obtains an allocation sequence number, a research assistant assigns identification codes to participants and records them in the case report forms (CRFs). Then, the result of patients’ allocation process will be informed to the acupuncturists.
Blinding
The acupuncturists are not blinded for the entire process. For eliminating potential bias, outcomes’ assessors and statisticians are blinded to group assignment. Patients’ allocation will be only revealed under some special conditions, such as severe allergy, serious infection, uncontrolled pain, etc.
Interventions
The ACE intervention is in agreement with the Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) guidelines. Patients in verum ACE group, sham ACE group, and WL group will receive real ACE therapy, sham ACE therapy, and delayed active ACE therapy 20 weeks later, respectively. The course of two ACE groups will contain 8 sessions, lasting over 8 weeks (one session per two weeks).
Verum ACE group
Acupoints:
ACE treatment is a semi-standard method in this study. According to the clinical practice, literature and the basic theory of traditional Chinese medicine, the prescription of ACE includes 6 obligatory acupoints and 2 groups of adjunct points.
The obligatory acupoints will include RN 12 (Zhongwan), ST 25 (Tianshu), SP 15 (Daheng), RN 06 (Qihai), RN 04 (Guanyuan), and GB 26 (Daimai). Adjunct acupoints will consist of 2 groups: acupoints of group 1 involving ST 36 (Zusanli), SP 09 (Yinlingquan), and ST 40 (Fenglong); acupoints of group 2 including BL13 (Feishu), BL20 (Pishu), and BL23 (Shenshu). The obligatory acupoints will be chosen in each session, and the adjunct points will be selected every other session. All acupoints will be localized according to the names and locations of acupoints drafted in 2006 by the National Standard of the People’s Republic of China (GB/T 12346-2006). Locations of acupunctures are presented in Table 1 and Fig. 3.
Table 1 Locations of acupoints in two ACE groups.
Acupoints
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Locations
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RN 12 (Zhongwan)
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On the anterior median line, 4 cun above the umbilicus.
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ST 25 (Tianshu)
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Level with the umbilicus, and 2 cun lateral to the anterior median line.
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SP 15 (Daheng)
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Level with the umbilicus, and 4 cun lateral to the anterior median line.
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RN 06 (Qihai)
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On the anterior median line, 1.5 cun below the umbilicus.
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RN 04 (Guanyuan)
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On the anterior median line, 3 cun below the umbilicus.
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GB 26 (Daimai)
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On the lateral abdomen, at the intersection of the vertical line of the free end of the 11th rib and the horizontal line on the same level of umbilicus, or 1.8 inches below LR 13 (Zhangmen) at the liver meridian.
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ST 36 (Zusanli)
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3 cun directly below ST 35 (Dubi), and 1 digit lateral to the anterior margin of the tibia
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SP 09 (Yinlingquan)
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On the medial side of the calf, in the sunk spot between the medial lower margin of the tibia and the medial margin of the tibia.
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ST 40 (Fenglong)
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8 cun directly below ST 35 (Dubi), and 2 digit lateral to the anterior margin of the tibia
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BL13 (Feishu)
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On the back, on the same level of the 3rd subspinous of thoracic spine, and 1.5 cun lateral to the posterior midline.
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BL20 (Pishu)
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On the back, on the same level of the 11rd subspinous of thoracic spine, and 1.5 cun lateral to the posterior midline.
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BL23 (Shenshu)
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On the back, on the same level of the 2rd subspinous of lumbar vertebra, and 1.5 cun lateral to the posterior midline.
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Preparation of ACE:
The catgut (Suzhou medical Co., Ltd., Jiangsu, China) with the length of 1.5 cm will be placed in front of an embedded needle (Zhengjianggaoguan medicine Co., Ltd., Shenzhen, China) for doing the operation. The preparation procedures of ACE will be performed under sterile conditions.
Operation Procedures of ACE:
Firstly, the acupuncturists should disinfect their hands with 75% alcohol and dress medical gloves, medical mask, and medical hat. Simultaneously, patients will lie on the bed, supine or prone position on the basis of location of acupoints, and will fully expose the skin of the acupoint area. Secondly, the acupoints’ regions will be sterilized with iodophor and alcohol twice by the acupuncturists. Simultaneously, an assistant will place the catgut in front of an embedded needle. Thirdly, the acupuncturists will locate the acupoint, and then, the needle will be embedded into the skin at the acupoints’ regions; consequently, the catgut will be embedded into the acupoints with the depth of about 1.5, 1 or 1 cm at the abdomen, lower limbs and back, respectively. The embedded needle will be withdrawn once the patient will have a feeling of sourness; meanwhile, catgut will leave under the tissue. Following this, sterile cotton balls will be pressed on the acupoints for hemostasis, and then, band-aids will be pasted on the acupoints to prevent wound infection. Eventually, the patients will be warned to avoid touching water on embedded acupoints for 24 h.
The frequency of the ACE treatment will be one per week, totally lasting for 8 weeks.
Sham ACE group
Patients in the sham ACE group will undergo similar procedures as the verum ACE group except that nothing will be put into the catgut embedding needles before operation, thus, no catgut will leave under the patients’ acupoint tissue after needle extraction. The prescription of acupuncture will also be as same as that in the verum ACE group.
In the current study, all the patients will be treated separately to avoid influencing each other. Both groups will be treated under the same conditions by acupuncturists, who will receive special training before participation in the study. In the whole ACE operation process, the acupuncturists and assistant will not talk about details.
WL group
The WLC group will not have any intervention. The patients will be asked to receive delayed ACE therapy for free after a waiting period of 20 weeks.
Magnetic resonance imaging (MRI) data acquisition
In this study, the MRI images of subcutaneous adipose tissue and visceral adipose tissue will be acquired by a MRI scanner (MAGNETOM; Siemens, Munich, Germany) with a matrix body coil of 18 channels at the MRI Center of Shenzhen Traditional Chinese Medicine Hospital. Before scanning, the participants will be trained for deep-breathing exercise. During scanning process, they will be asked to hold their breath for about 15 s. The sequence parameters are as follows: flip angle, 65°; repetition time (TR)/echo time (TE), 195/3.69 ms; the number of excitation (NEX), 1; matrix, 256×131; slice thickness, 7 mm; and echo train length, 4. In order to guarantee the passage of image plane through the center of the vertebral disc between L4 and L5, the MRI data will be acquired from a sagittal scout. Qualitative image analysis will be performed by two independent reviewers as well.
Outcome measurement
The clinical outcomes will be use to assess patients’ obesity levels and their quality of life. All measurements will be undertaken at baseline (after 8 weeks of treatments, and at 12 weeks of follow-up).
The primary outcome is the change of BMI from baseline. The BMI is calculated as follows: BMI = mass (kg)/ (height(m))2. According to the BMI-based criteria presented by the WHO and Asia-Pacific classifications in 2000, BMI scores are ranked as “23.0 - 24.9 (pre-obesity),” “25 - 29.9 (level Ⅰ of obesity)”, and “more than 30 (level Ⅱ of obesity)”.
The secondary outcomes will include WC, hip circumference (HC), waist-hip ratio (WHR), body fat percentage (BFP), and the WHO Quality of Life (WHOQOL). WC will be measured by a stretch-resistant tape at the midpoint between the top of the iliac crest and the lower margin of the least palpable rib. In addition, HC will be measured around the widest portion of the buttocks using a tape parallel to the floor [23]. Besides, BFP will be measured with bioelectrical impedance.
WHOQOL is a widely used questionnaire for measuring the physical and mental health status. WHOQOL scale includes 26-item, involving four domains of patient’s quality of life: physical, psychological, social, and environmental [24, 25]. The total score ranges from 0 to 100. The lower the score, the poorer the patient’s quality of life.
Here, other outcome parameters, including basal metabolic rate, blood pressure (BP), heart rate (HR), total cholesterol (TC), triglyceride (TG), and high-density lipoprotein (HDL) levels will be tested at each time-point.
Statistical analysis
The statistical analysis will be conducted by independent statisticians who will be blinded to group allocation and intervention methods. Before data analysis, the research group will draw up a statistical plan, including the required data and method of data processing.
Data will be analyzed by using SPSS 22.0 software (IBM, Armonk, NY, USA). For MRI data, the images will be analyzed on a workstation (Syngo Multimodality Workplace) for the quantification of VAT and SAT.
Demographic information and levels of measured variables are analyzed by descriptive statistics. Categorical data are described as percentage (n%) or analyzed using the Chi-square (x2) test. Additionally, for continuous variables, if data are normally distributed, one-way analysis of variance (ANOVA) is used to detect differences among the 3 groups. Otherwise, the Kruskal–Wallis (K-W) test can be considered. The longitudinal and repeated measured data are analyzed by the repeated measure analysis.
In this study, SFA is quantified as an area between outline of abdominal skin and the outer abdominal muscle, while VFA is defined as enterocoelia and retroperitoneal region between the inside edge of abdominal muscles and the spinal front. Detailed methods have been described previously [26-28]. The correlation coefficients between two reviewers who analyzed the same image for SFA and VFA (n=30) were r=0.99, P<0.001 and r=0.98, P<0.001, respectively.
Eventually, the Pearson’s correlation between the changes of SFA and VFA and improvement of clinical variables will be calculated in each group.
For the above-mentioned statistical analyses, a P-value < 0.05 is considered statistically significant.
Safety
To guarantee that the ACE operation is standard and safe, the acupuncturists in this study should pay attention to those announcements as follows: (1) perform aseptic operation strictly to prevent infection; (2) catgut should not be embedded in adipose tissue that could prevent fat liquefaction; (3) catgut should not be exposed to body surface to prevent infection; (4) master the angle and depth of the embedding in order to avoid injury to the internal organs, great vessels, nerve, etc.; (5) acupoints can’t touch water for 24 h after embedding; (6) informing patients’ acupoints embedded catgut may keep sensation of soreness, distension and numbness for one or two days, and even more than three to five days.
Management of adverse events
ACE therapy may lead to different AEs, such as fainting during operation, subcutaneous hematoma, allergy, infection, severe pain, etc. Any experienced AEs by participants should be reported to the researchers. After confirming the validity of the AEs by an evaluator, the acupuncturists will immediately stop the treatment procedure and deal with the AEs. All the AEs, as well as managing the AEs, will be carefully recorded during treatment and follow-up phases.
Quality control
Acupuncturists, assistants, data collectors, and statisticians who participated in the study should abide the rules and regulations. Before the study, each researcher took a basic study training to understand design, purpose, and basic information of this research. The acupuncturists should be at least 3 years of practical acupuncture experience, and they also should be familiar with the operation process and be able to cope with any possible AEs. Data collectors are responsible for saving and managing various data, and strictly proofread data. Patients’ withdrawal and AEs during the study will be recorded in detail. Statisticians will be fully responsible for data management and statistical analysis. Regular team meetings will be held and fully documented.
Ethical approval
This study was approved by the Chinese Clinical Trial Registry. The registration number of this trial is ChiCTR1800020248. In addition, the study protocol was approved by the Ethics Committee on Shenzhen Traditional Chinese Medicine Hospital. Prior to start of the study, patients will be informed about the potential risks of the study. Patients voluntarily participated in the study with informed consent. If the protocol requires to be amended, all the materials on trial will be reported to the Ethics Committee, and the amended protocol can be only implemented after consent acquirement.
Data management and monitoring
The research associates will record the information on the CRFs, and verify that the data will be fully, swiftly, and accurately collected. The private information and medical records of patients, including their name, phone number, and ID number, will be anonymous to ensure confidentiality. All the research documents will be kept in specialized cabinets and preserved for at least 5 years after publication.
In addition, the data monitoring committee is established consisting of experienced experts in Good Clinical Practice Department of the Shenzhen Traditional Chinese Medicine Hospital, to periodically review the progress of the trial, and monitor collection of the data, allocation concealment, etc. The modification or termination of the trial can be performed by the committee. The data monitoring committee is independent from the sponsor and has no conflict of interest.