Study Objectives
Obesity is a complex disease caused by an interaction between genetic predisposition, environmental factors, and host metabolic disorders. This prospective cohort study will evaluate the efficacy and safety of various exposure factors, including TCM therapy, in the intervention of individuals who are overweight or obese to achieve the following three objectives:
(1) To perform a cohort study to allow the long-term follow-up of patients to observe the long-term efficacy and the systematic evaluation of the clinical efficacy of TCM based on the percentage of weight change, rebound rate, and other indicators.
(2) To identify the personalized molecular network driven by the clinical characteristics of the overweight/obese population through the clinical-molecular network feature representation, develop a method for complex disease classification based on the similarity between the nodes of the personalized molecular network, construct an effective and robust overweight/obese disease subtype classification system, identify key genes, and clarify the clinical heterogeneity of the overweight/obese population. Understanding the complexity of metabolic disorder phenotypes
(3) To reveal the mechanisms and biological connotations of metabolic disorders in different subtypes of overweight and obesity from the perspective of microorganisms through a new generation of 16S rRNA full-length sequencing technology and metabolomics studies. A network of TCM clinical phenotype-microbial functional groups and metabolites will be constructed
Research Methods
Study Design
A prospective cohort study was designed with prospective data collection and long-term follow-up of the enrolled patients. This long-term study aims to observe the effects of various exposure factors represented by traditional Chinese medicine treatment on weight loss in overweight/obese subjects.The overall flow of the study can be seen in Fig. 1.
This study was approved by the Ethics Committee of Hubei Provincial Hospital of Traditional Chinese Medicine (No: HBZY2022-C08-02). It was prospectively registered in the Chinese Clinical Trial Registry (ChiCTR2200063126), and any changes will be recorded immediately.
Sample size calculation
The results of double-blind placebo-controlled studies of TCM interventions in patients aged 18–60 years suggested that 72.22% of participants in the exposed group lost > 5% of their body weight compared to 36.84% in the non-exposed group. In this study, a = 0.05 and power = 90% were used to obtain n = 40 cases. Considering the proposed 1:1 grouping, the exposed and non-exposed groups included 40 cases each. According to a previous study, only 20% of adults who try to lose weight or maintain weight can maintain their diet and exercise habits. Considering the loss and refusal to follow up, at least 200 participants in the exposed and non-exposed groups were required; thus, a total of at least 400 participants were included.
Study Process
Inclusion and exclusion criteria
Diagnostic criteria
(1) Overweight: 24.0 kg/m2 ≤ BMI ≤ 27.9 kg/m2;
(2) Obesity: BMI ≥ 28kg/m2;
Inclusion criteria
(1) Age: 18–65 years, regardless of sex;
(2) Recent stable weight and BMI ≥ 24.0 kg/m2;
(3) Good compliance and willingness to follow the principles of follow-up
(4) Agreement to sign an informed consent form
Exclusion criteria
(1) Complicated by serious diseases of the heart, liver, lung, kidney, brain, blood, and neuropsychiatric system.
(2) Pregnant and lactating women
(3) Current use of exogenous insulin and drugs affecting glucose metabolism.
Withdrawal or drop-out criteria
The subjects have the right to withdraw from the study at any time for any reason. The investigators should contact subjects by telephone, follow-up, or through relatives to obtain a complete picture of the reasons for withdrawal.
The investigators also have the discretion to withdraw participants from the study in case of disease recurrence, adverse events, treatment violations, administration, or other reasons. Excessive dropouts may lead to unreliable results; therefore, unnecessary dropouts should be avoided. Subjects who withdraw from the study because of an adverse event or abnormal laboratory test results will be recorded in the case report form.
Participants will discontinue their study participation early for any of the following reasons:
(1) Protocol violation: Violation of the main content of the protocol, especially when it is related to the safety of the participants
(2) Loss of follow-up and withdrawal of informed consent
(3) Intolerable adverse events: The subjects' health status does not allow them to participate in the study.
(4) The reasons for dropping out in all cases will be recorded in detail, the end-point specimens will be retained, and the common reporting format (CRF) table will be retained for future reference.
Screening Phase Assessments
Demographic data for each participant will be collected, including name, sex, ethnicity, identity card, current address, telephone number, contact person, and telephone number.To confirm that the participants meet all the inclusion criteria and none of the exclusion criteria, the participants will sign an informed consent form.
Medication records
During each follow-up period, all concomitant medications from the last follow-up to the current follow-up and the dosage and medication time will be recorded.
Baseline Visit
The clinical symptoms, past medical history, family medical history, concomitant medications, and assessments required at the current visit are as follows:
(1)Laboratory tests
Blood routine + hsCRP, routine urine, liver, and kidney function, five items of thyroid function, glucose tolerance test /0h, postprandial 2h blood glucose (standard anhydrous glucose test) measurement, insulin challenge test /0h, postprandial 2h insulin measurement, measurement of the levels of the full set of sex hormones, and 25-hydroxyvitamin D levels
(2)Morphological indicators
Body fat percentage, skeletal muscle content, body weight, skeletal muscle fat, BMI, body fat percentage, visceral fat area, water, neck circumference, and whole-body phase angle
(3)Imaging examination
Abdominal color Doppler ultrasonography, uterine adnexal color Doppler ultrasonography, abdominal computed tomography, or abdominal magnetic resonance imaging (optional)
(4) Four diagnostic examinations of TCM
Tongue examination, pulse examination, clinical symptoms, and TCM constitution questionnaire
(5)Health questionnaires and psychological function tests[17]
Diet questionnaire, International Physical Activity Questionnaire (IPAQ), Generalized Anxiety Disorder Scale (GAD-7), Depression Screening Scale (PHQ-9), Pittsburgh Sleep Quality Index (PSQI), Quality of life scale (SF-36)
(6)Blood sample collection
The patients will be required to sign a separate informed consent form for the donation of additional biological samples.
(7)Tongue coating and fecal sample collection
The patients will be required to sign a separate informed consent form for the donation of additional biological samples.
Follow-up observation recording protocol
During weeks 12, 24, 48, and 96 of the study, the participants’ daily behaviors related to weight management will be recorded in detail. The participants will be divided into exposed group and non-exposed group according to whether they received comprehensive TCM intervention during the observation period.
During the follow-up period, we will regularly organize offline health education events for the public to communicate the objectives, significance, and anticipated outcomes of the research. We will leverage channels such as social media, health talks, and public speeches to increase public awareness of overweight and obesity issues and to inform them about the opportunity and benefits of participating in the research.
Through the involvement of patients and the public, we aim to ensure the importance, credibility, and sustainability of the study. Their feedback and experiences will provide valuable guidance for improving and optimizing the research design and implementation.
Combined treatment
(1)TCM decoction:According to the electronic medical record system, the specific medication prescriptions of the patients during the follow-up period were faithfully recorded, and the specific prescription was implemented according to the Expert Consensus on the Diagnosis and treatment of Obesity in Traditional Chinese Medicine[18]. The traditional Chinese medicine was decocted by the hospital pharmacy, decocted twice with water, filtered and stewed to 400mL, twice a day, 200mL each time. At the next visit, the duration of medication was recorded.
(2)TCM techniques: Acupoint catgut embedding treatment was performed once every 10–14 days, and 3 months was a cycle. According to the electronic medical record system, the number of catgut embedding in the follow-up period of the patients was recorded. The acupoint selection was referred to Chinese medicine practice guide for acupoint catgut emlbedding in treating non-alcoholic fatty liver disease [19].
(3)Intermittent fasting with TCM (IF): The samples were given intermittent
fasting therapy of traditional Chinese medicine for 1 or 2 days a week, with Lingguizhugan decoction as the main prescription (Poria coix 10g, cinnamon twig 6g, fried Atractyloides atractyloides 20g, Glycyrrhizae radix 20g, Radix astragali 30g, yam 20g, Tangerine peel 6g, Coix seed 30g, Epimedium 10g, morula officinalis 10g, mulberry 15). Dandelion 15g, white cardamom 10g) add water 3500ml fried to about 2000ml drinking. Patients were followed up for 3 months in a cycle, and the number of days of intermittent fasting per week was recorded according to patients' self-reports.
Protocol for recording the long-term visit period
During the follow-up period, online or offline follow-ups will be performed once every 48 weeks until the participant withdraws or is automatically dropped out. The evaluation window is defined as +/-1 week of each follow-up date.
Online follow-up
(1) Health questionnaire and psychological function tests: Diet questionnaire, IPAQ, GAD-7, PHQ-9, PSQI, SF-36, and TCM Constitution scale questionnaire.
(2) Weight management
On-site follow-up
(1) Evaluation of the self-management interventions
(2) Review of evaluation items
(3) Concomitant medications and adverse events were recorded.
(4) Collection of biological samples (e.g., blood, urine, tongue coating colonies, and feces).
Evaluation index standard[20, 21, 22]
Primary outcome measures
Statistically significant difference in the percentage of weight loss from baseline of > 5%.
Secondary outcome measures
(1) Improvement rates of waist and hip circumferences
(2) Incidence of obesity-related complications, including metabolic syndrome, prediabetes mellitus, type 2 diabetes mellitus, abnormal lipid metabolism, hypertension, nonalcoholic fatty liver disease (or metabolic fatty liver disease), polycystic ovary syndrome, female infertility, male hypogonadism, obstructive sleep apnea syndrome, asthma and/or reactive respiratory disease, osteoarthritis, stress urinary incontinence, gastroesophageal reflux syndrome, gout, cardiovascular and cerebrovascular diseases, and tumors.
Other evaluation methods of observation indicators
(1) Improvement of morphological indices
(2) Changes in the combined clinical symptoms
(3) Diversity of the intestinal and tongue coating microbiota
(4) Diet and exercise habits.
(5) Neuropsychiatric safety indicators (depression, anxiety)
Biological sample collection
Blood samples (5 ml×3 tubes of fasting venous blood) will be collected from all enrolled participants according to uniform standards by professional nurses in the morning. After a short time, the samples will be centrifuged at 3000 RPM for 10 minutes, the serum will be separated into plastic tubes, sealed and coded, and stored in a refrigerator at -80℃ (whole blood: 0.5 ml×3 tubes; serum: 0.5 ml×3 tubes) and provided to the Hubei Provincial Hospital of Traditional Chinese Medicine for storage.
Tongue coating and stool sample collection and processing: The participants will be instructed to not drink or eat colored food and beverages for 8 h before collecting tongue coating samples. The tongue coating specimens will be scraped by routine aseptic manipulation and stored in 1.5 ml EP tubes containing phosphate-buffered saline (PBS). Stool samples (≥ 2 g) will be transferred to sterile stool collection tubes by the participants themselves following instructions from specialized personnel. The participants will be instructed to return the samples within 60 minutes after collection. The samples will be stored at − 80° C or, if not feasible, at − 20°C.
Statistical Analysis
Data will be tested for normal distribution using the Shapiro–Wilk test. Normally distributed measurement data will be described as mean ± standard deviation (x ± s) and analyzed by t-test or variance analysis. Data without normal distributions will be described as medians and interquartile ranges (IQRs) and analyzed using Mann–Whitney and rank-sum tests. Count data will be described as the number of cases and percentages (%), and analyzed using the chi-square test (2). Fisher’s exact probability method will be used when the conditions of the chi-square test are not met. The cumulative incidence of weight regain in participants with obesity, progression to diabetes in participants with prediabetes, and reversion of prediabetes in participants with prediabetes will be analyzed using the Kaplan–Meier method, and the log-rank test to evaluate the statistical significance. A Cox proportional hazards regression model will be used to analyze the association between multiple integrated TCM and Western medicine interventions, disease progression, and treatment effects after adjusting for possible confounding factors such as age, sex, family history, drinking history, diet, and exercise habits. Statistical significance is set at P < 0.05.
(1) Primary efficacy evaluation indicators: Relative percentage weight change and weight loss response rate
(2) Secondary efficacy evaluation indicators: visceral fat content (detected by computed tomography or magnetic resonance imaging), incidence of metabolic associated fatty liver disease (MAFLD) (including the incidence of fatty hepatitis, fatty liver fibrosis, cirrhosis, and liver cancer), incidence of type 2 diabetes mellitus, improvement rate of Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), improvement rate of liver fat content, diversity of intestinal microbiota, incidence of obesity-related endpoint events (including diabetes and high fat), blood pressure, cardiovascular and cerebrovascular diseases, cancer, and other metabolic-related diseases), neuropsychiatric safety indicators (depression, anxiety, etc.);
(3) Safety analysis: First, according to the requirements for the correlation of adverse reactions, the adverse events and adverse reactions of the two groups will be listed, including the number of cases of various adverse events, the number and conversion rate of laboratory test indicators from "normal to abnormal" or "abnormal aggravation" before and after the test, and the reasons and explanations. The chi-square test will be used for the statistical analysis of adverse reactions.
(4) Missing values: Data may be missing at a specified study visit for the following reasons: the visit occurs but the data were not recorded or could not be seen; no visit occurred; or the participant withdrew from the study before the visit.
The last-observation-carried-forward (LOCF) method will be used to account for missing data. The last observed response will be assigned to the subsequent missing point and the last observed response will be defined as the endpoint.
Data Preservation
The investigators will maintain all study data, including the identification of all subjects (such that different records such as CRFS and hospital original records can be effectively checked), all original signed informed consent forms, all CRFS, detailed records of drug distribution, etc. The retention period will be 5 years after the end of the study.
All the data from this clinical trial belong to the research group. No data will be provided to any third party without receiving written consent from the research group.
Ethical Requirements
The study will be conducted in accordance with the principles of the Declaration of Helsinki and Chinese regulations on clinical research. The study protocol was reviewed and approved by the Ethics Committee of Hubei Provincial Hospital of Traditional Chinese Medicine.
The study physician will provide a complete and comprehensive description of the purpose, nature, procedures, and possible benefits and risks of the study to each participant or their designated representative before enrollment in the no-event group. The participants will be made aware of their right to withdraw from the study at any time. A written informed consent form will be provided to each participant before enrollment so that the participant could provide consent. Participants who voluntarily sign an informed consent form will be selected for clinical research. Informed consent forms will be preserved as original clinical trial data for future studies. To protect privacy, the participants’ names will not appear on the case report form. The investigator will confirm and record the coded identity of each participant. All adverse events will be recorded and serious adverse events will be reported immediately to the governing Human Research Ethics Committee.