Review Article Acupoint Catgut Embedding for Obesity: Systematic Review and ... - Semantic Scholar

20 Pages·2015·1.29 MB·English

Hindawi Publishing Corporation
Evidence-Based Complementary and Alternative Medicine
Volume 2015, Article ID 401914, 20 pages
http://dx.doi.org/10.1155/2015/401914
Review Article
Acupoint Catgut Embedding for Obesity: Systematic Review and
Meta-Analysis
TaipinGuo,1YulanRen,2JunKou,2JingShi,3SunTianxiao,2andFanrongLiang2
1SchoolofAcupuncture-MoxibustionandTuinaandRehabilitation,YunnanUniversityofTraditionalChineseMedicine,
Kunming650500,China
2SchoolofAcupuncture-MoxibustionandTuina,ChengduUniversityofTraditionalChineseMedicine,Chengdu610075,China
3YunnanProvinceHospitalofTraditionalChineseMedicine,Kunming650021,China
CorrespondenceshouldbeaddressedtoFanrongLiang;[email protected]
Received8May2015;Accepted16July2015
AcademicEditor:MariangelaRondanelli
Copyright©2015TaipinGuoetal.ThisisanopenaccessarticledistributedundertheCreativeCommonsAttributionLicense,
whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
Acupointcatgutembedding(ACE)wasappliedwidelytoantiweightinChina.Theaimofthisreviewistoestimatetheeffectiveness
andsafetyofACEonobesity.AliteraturesearchwasconductedinPubMed,CochraneLibrary,EBASE,CNKI,andsoforth,using
combinationsubjecttermsofobesity(oroverweight,weightloss,etc.)andacupointcatgutembedding(orcatgutimplantation,
catgut embedding). Improvement rate, reduction of body weight and body mass index (BMI), and so forth were analyzed. 43
studieswereincludedforsystematicreviewandmeta-analysis.Althoughwithpoormethodologicalquality,ACEwassuperiorto
manualacupuncture(MA),sham,andcuppinginimprovementrateandpresentedabettertendency(OR > 1)comparedwith
drugsandelectroacupuncture(EA).MeanvaluesofweightlossbyACEwere1.14kg,1.26kg,1.79kg,and3.01kgcomparingwith
2 2 2 2
MA,drugs,EA,andsham,respectively.MeanofBMIreducedto0.56kg/m ,0.83kg/m ,0.79kg/m ,and1.63kg/m comparing
withMA,drugs,EA,andsham.Lessadverseeffectswerereported.Pooledoutcomespresentedatendencyofequalorsuperior
effectstootherinterventionsandfewersideeffects.FuturehighqualitytrialswithrigorousdesignandpositiveFDAapproveddrug
ascontrolareurgenttoassesstheeffectofACEforobesity.PROSPEROregistrationnumberisasfollows:CRD42015016006.
1.Introduction 2.3 billion people may suffer overweight and 0.7 billion get
obesity.
Obesity, a common kind of metabolic disease, is character- According to WHO report in 2005 [6], obesity was
izedbyredundantaccumulationandabnormaldistribution deemedoneofthetoptenriskfactorsformanydiseaseslike
of fat. With transformation of modern lifestyle and diet hypertension, diabetes, cardiovascular disease, stroke, and
structure, such as more intake of refined food and less many cancers, and nearly 2.6 million people died directly
physical activity, the prevalence of overweight and obesity due to obesity or overweight every year. Studies [7, 8] by
is increasing amazingly in either developed countries or working group on obesity in China (WGOC) revealed the
developing ones. Particularly in the last decade, the growth morbidity rate of hypertension was 2.5 times higher when
rateofobesityhasascendedexponentially.Forexample[1,2], the body mass index (BMI) ≥ 24kg/m2 than when BMI <
the morbidity was 10% ∼40% in most European countries, 24kg/m2 and 3.3 times higher with BMI ≥ 28kg/m2 than
anditwasupto35.5%in2009∼2010inAmericaincontrastto with BMI < 24kg/m2. Specifically, central obesity seemed
30.5%in1999∼2002and22.9%in1988∼1994.Withtheworld’s moredangerousthansystematicobesity,andevenwithmild
most populous country being China, the obesity morbidity obesitythemorbidityandmortalityofcoronaryheartdisease
was just 1.5% in 1992, 7.1% in 2002, and up to 18% in 2011 increasedwhenthewaistcircumferencegotbigger[9–11].So,
[3, 4], and in some region it reached 37.71% [5]. According healthproblemissuperiortoaestheticsinobesity,anditurges
totheprediction[6]ofWorldHealthOrganization(WHO), findinganicetreatment.
2 Evidence-BasedComplementaryandAlternativeMedicine
Althoughtheetiologyandpathogenesisarestillunclear, A study showed there were 1088 articles of weight loss
manyclinicalpracticeguidelineshavebeendevelopedworld- usingTCMinCNKIdatabaseby2012,andmostofthemeth-
wide by relative medical and health organizations based odswereherbsandacupuncture[23].Chineseherbwasused
on the existing evidences. For instance, with the American tostrengthenspleenand𝑞𝑖andhavebowelmovement,and
Clinical Guidelines of Overweight and Obesity released radix astragali, bighead Atractylodes rhizome, and rhubarb
by National Heart, Lung and Blood Institute (NHLBI) of werethemostusedones[24].However,thesideeffectslike
National Institutes of Health (NIH) since 2000 and with lackofstrengthandanorexiaweredifficulttoavoid[25].
the reassessment of new evidences by American College of RCTs [26–30] manifested acupuncture was useful to
cardiology(ACC),AmericanHeartAssociation(AHA),and reduceBMI,waist,andabdomencircumferenceandimprove
NHLBI, a new version of guideline for the management of the quality of life, featuring less side effects, multifarious
overweight and obesity in adults bas been made in 2013 intervention means like ACE, auricular needle, EA, hand
[12].Besides,Canada,China,andEuropehavealsopublished acupuncture,auricularplaster therapy,andso on.Areview
their prevention guides, which promoted the concern and [31] of RCTs indicated acupuncture seemed more effective
managementofobesity[4,13,14]. comparingtowesternantiobesitydrugs;themeanofweight
Obviously, the therapies of obesity are much similar in reduction was 0.65kg by acupuncture and 0.08kg by TCM
2
all the guidelines, consisting of the lifestyle modification drugs, and the mean of BMI reduction was 0.83kg/m by
of diet and exercise, drug, surgery, and complication ther- acupunctureand0.18kg/m2byTCMdrugs.
apy. Restriction of high calorie diet intake and increase of However, owing to the long-term adherence of anti-
physical activity are recognized as the primary and most weight drugs, the conflict of time between treatment and
valid type of antiobesity, particularly for children because daily work, and high expense of treating, more patients
of the prohibition of drug and surgery in children’s weight abandoned therapy. Hence, the method of ACE, developed
loss by American Food and Drug Administration (FDA). fromTCMacupuncturewithacertainsectionofabsorbable
Studies[15,16]alsoshowedreductionofhigherenergyfood catgut suture implanted in acupoint, characterized by easy
intake such as high glucose and high fat and/or increase of operation,durableandstrongstimulation,andlonginterval
physicalactivitycouldimprovebodilyfunctionsandreduce between each treatment, has broadly been used to lose
fat. However, Cochrane system review [17] indicated that, weightinChina.Despitelackofeffectivenessevaluatedand
due to insufficient longer-term evidences, the short-term normative management plan, most Chinese TCM hospitals
adjustmentoffoodconsumptionandmovementwasdifficult and weight loss institutions have conducted ACE to treat
toachievesustainedweightreduction.Thechangeofdietand obesitybasedontheirownexperience.Toestimatethesafety
activityhabitshapedformanyyearswasdifficulttoadhereto andeffectappearedtobeespeciallyimportant,anditwasalso
foralongtime,andthisledtothefailureofweightlossfor necessarytoprovideatreatmentsuggestionbasedoncurrent
weightregain[18]. evidences.Theprimaryaimsofthissystematicreviewareto
So far, American FDA approved only 4 short-time use estimatetheeffectivenessandsafetyofACEonobesityand
drugsasphentermine,diethylpropion,phendimetrazine,and formulateatreatmentsuggestion.
benzphetamine and 3 medium- and long-time use ones as
orlistat, lorcaserin, and phentermine plus topiramate-ER.
2.Methods
Although these antiweight drugs were tested to be effective
by comparison with placebo, there are 5% of them that
were invalid [19]. Besides, there were so many obvious 2.1.StudySelection(InclusiveandExclusiveCriteria)
side effects like headache, dizziness, nausea and vomiting,
2.1.1.TypesofStudy. ToevaluatethecurativeeffectsofACE
insomnia,drymouth,tastealteration,diarrhea,constipation,
onobesityandweightloss,thisreviewwasconfinedtoRCTs
hypoglycemia,andchangeofcognitionthattheharmbrought
comparingACEwithacontrolgroup,whichcontaineddrug,
aboutbythemwasmorethanobesityitself,andthesedrugs
no treatment, placebo, diet and exercise therapy, and other
frequentlyfailedindecreaseofcardiovascularmorbidityand
types of acupuncture like MA, EA, ear auricular pressure
mortalityandmedicalcostsinthelongrun[19].Theefficacy
treatment, acupoint pressure, and so forth. It is deemed
and safety were still under suspicion, and it may be related
a randomized study if the trial stated the “randomization”
totheambiguityofobesitypathogenesisthatthedrugaction
phrase,andtheblindingwasnotrestricted.Besides,Chinese
washardtoselectivelycutdowntheadiposetissueandthere
and English were the limitation of language. The animal
wasnoharmofhealthatmolecularlevel[20].Theoperative
mechanismstudies,casereports,self-pre-andpostcontrol,or
treatmentofobesitywasintendedforobeseadultwithserious
non-RCTswereexcluded.
complicationspecificallycausedbytheexcessofadiposecell
likemetabolicsyndrome,andthesurgicalsitesweremostly
restrictedatstomach,duodenum,pancreas,andgallbladder 2.1.2.TypesofParticipants. Itincludedtheparticipantswith
todecreaseorconstrainthefunctionofdigestivesystem[21]. nolimitationofage,gender,andtypeofoverweightorobe-
Consideringthesidereactionandthatthereisnobenefit sity, including children obesity and abdominal obesity. The
to cardiovascular risks in antiobesity drugs and the high definitionsofobesityoroverweightusingBMI,bodyweight,
riskandnarrowuseofsurgery,moreclinicianshaveapplied or percentage of weight excess compared with ideal weight
complementary and alternative therapy including TCM to wereincluded.Patientswithseveremedicalconditions,who
loseweight[22]. arepregnant,andwithdrug-inducedobesitywereexcluded.
Evidence-BasedComplementaryandAlternativeMedicine 3
2.1.3. Types of Intervention. Clinical trials estimating the using𝐼2 values,andrandomeffectmodelwaschosenwhen
treatment of ACE used alone were included. Studies with 𝐼2 > 50% or fixed effect model when 𝐼2 < 50%. An odds
cointerventions of drugs and other types of acupuncture ratio (OR) > 1 suggested greater reduction of body weight
such as MA, EA, massage, pressure, and laser acupuncture (≥2kg)orBMI(≥0.5kgm−2)intheACEgroupthancontrol
wereincludedifthesameinterventionascontrolandother groupincalculationofdiscretedata.Thecalculationofmean
cointerventions were excluded. The control interventions differences of changes in body weight and BMI between
withothertypesofacupuncture,drugs,notreatment(wait- ACE and control groups was also conducted. Because of
listedortreatmentasusual),placebo(nocatgutimplanted), mostliteraturesshowingonlypre-andposttreatmentvalues,
anddietorphysicalactivitytherapywereincluded.Studiesto meanchangewasobtainedbysubtractingpretreatmentfrom
comparetheeffectofdifferenceofcatgutlength,operation, posttreatmentvaluesandstandarddeviation(SD)changewas
oracupointprescriptionwereexcluded. calculatedbythegivenpre-andposttreatmentSDaccording
toCho’sformula[75].
2.1.4. Types of Outcome Measures. The primary outcomes
consisted of improvement rate, reduction of body weight,
3.Results
BMI, hip circumference (HC), and waist circumference
(WC). Secondary outcomes included the side effects, such 3.1. Study Description and Participants. Our initial search
as bleeding, serious discomfort, subcutaneous nodules, and identified958probablearticlesfromthedatabases,ofwhich
infection.Treatmentsuggestionsincludingfrequencyofacu- 386 were reserved with 572 excluded for duplication. 47
pointprescription,frequencyoftreatmenttime,andcourse articleswereselectedatthescanoftitlesandabstractsbased
werealsoshownaccordingalltheincludedRCTs. ontheinclusiveandexclusivecriteria.Finally,43studieswith
3520participantsmettheinclusioncriteriaandwereincluded
2.2. Data Sources and Search Methods. A literature search to this systematic review with 2 nonrandomizations and 2
was conducted up to November 2014 in the databases redundantpublicationseliminatedbyfulltextview.Inthese
of PubMed, Cochrane Library, EBSCO, Web of Science, 43trials,therewere30articles[32–61]reportingtheweight
EBASE,Springer,WHOInternationalClinicalTrialsRegistry losseffectofACE(1241patients)withMA(1096patients),4
Platform (ICTRP), CNKI, Wanfang, CBM, and VIP, using ACE(153patients)versusdrugs(165patients)[62–65],5ACE
the combination subject terms of obesity (or overweight, (155 patients) versus EA (155 patients) [58, 66–69], 2 ACE
weight loss, weight control, weight reduction, and slim) (88 patients) versus sham (88 patients) (that with the same
and acupoint catgut embedding (or catgut implantation, operationasACEbutthecatgutwasnotimplanted[70,71]),
catgut embedding). The item of RCT was also chosen in 1ACE(40patients)versuscupping(40patients)[72],2ACE
corresponding databases and the languages of Chinese and plusEA(66patients)versusEA(57patients)[73,74],and2
Englishwererestricted. ACEplusMA(91patients)versusMA(85patients)[42,43],
andalltheincludedtrialswerefromChina.Thearticleswere
filtratedasshowninFigure1.
2.2.1. Data Extraction and Quality Assessment. Each liter-
ature of title and abstract was scanned by two reviewers
(Taipin Guo and Sun Tianxiao) who have been trained 3.2. Risk of Bias in Included Studies. As shown in Figure2,
and gained certifications in Chinese Cochrane Centre. All themethodologicalqualityofallthe43articleswaspoorand
relevantarticlesoffulltextwereinvestigated.Theextracted probablyinhighriskwithalmostnoreportsofbothalloca-
informationincludeddescriptionsofstudies,characteristics tionconcealmentandblindingofparticipants,acupunctur-
ofparticipants,interventionsofbothobservationgroupand ists, or statisticians except 1 reported, respectively [38, 70].
control group, adverse effect, and quality. Risk of bias was Only18of43reportedtherandomsequencegenerationwith
usedtoevaluatethequalityofstudy.Thedecisionofriskwas 13 [33–35, 41, 46, 48, 50, 53, 60, 61, 68, 70, 72] in low risk
madebytworeviewers.Ifinconsistentresultsappeared,the and5[44,51,57,63,74]inhighrisk.Thesimplesizevaried
finaldecisionsweremadebyalltheauthors.Formissingor from 20 to 150 participants (20 to 150 participants in ACE
ambiguous data, we tried to contact the author as possible, groupsand20to90incontrolgroups).Twoarticles[63,70]
andforduplicatepublicationweonlyselectedtheoriginal. reportedasmallproportionofdropoutwhosedatawasalso
excluded from analysis, but the reasons were not given or
2.2.2. Measures of Publication Bias and Treatment Effect. clearly described. None of them stated the calculation of
Review Manager (version 5.1, the Nordic Cochrane Centre, samplesize.MoredetailswerereportedinTable1basedon
Copenhagen,Denmark)wasappliedtoassesscurativeeffect EBM PICOs (patient, intervention, control, and outcomes)
and publication bias. Forest plot was used to illustrate the principle.Becauseallofthestudiesdidnotpublishthetrial
relative strengthof curative effect. Meanwhile, accordingto protocolsorregistration,theselectivereportingofoutcomes
Cochranehandbooksuggestion,thefunnelplotwaspictured cannotbejudged.
to describe publication bias visually as the number of trials
wasmorethan10.Therewasnopublicationbiasasasymmet- 3.3.Comparison1:ACEversusMA
ricinvertedfunnelwhilethepublicationbiasorasystematic
difference of small or big sample size effects existed as an 3.3.1. Frequency of Improvement. There were 30 trials with
asymmetric funnel. The heterogeneity result was indicated 2392patients[32–61]inthecomparisonofACEversusMA
4 Evidence-BasedComplementaryandAlternativeMedicine
Ct. NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR
s
ct
e
ff
e
e
d
Si
ACE NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR
Ct.) effect / / / / / / / / / / / / / / / / / IR
s o
u N
s
r
e
v
E
C P,
A F
obesity. Outcome( Withbenefits IR,BW,BMI / IR,BW,FP IR IR IR IR C,THC,HC,BM HDL / / / IR / IR IR,WHR IR /
or W
f
E
csofRCTsofAC FrequencyofCt.(totaltimes)1per1-2day(s)(45)1per1-2day(s)(19) 5per1week(10) 1per2days(15) 1per2days(15) 1per1day(30) 1per2days(23) 1per2days(63) 6per1week(48) 1per2days(28) 3per1week(24) 1per1-2day(s)(38)1per1-2day(s)(20) 1per2day(14) 1per1day(30) 1per1-2day(s)(25) 1per1day(52) 1per1day(63)
ble1:Characteristi FrequencyofACE(totaltimes) 1per20days(3) 1per1week(4) 1per1week(2) 1per10days(3) 1per10days(3) 1per1week(4) 1per15days(3) 1per2week(9) 1per1week(4) 1per1week(8) 1per10days(6) 1per35days(2) 1per8days(3);1per15days(3) 1per2weeks(2) 1per1weeks(4) 1per2weeks(4) 1per15days(4) 1per1month(3)
a
T Ct.
ntion pesof MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA
ve Ty
r
e
Int AcupointsofACE I11,RN12,ST25,RN6,SP9,SP6,AShi ST34,RN12,ST25,RN9,ST40 SI4,BL22,BL17 NotGiven RN12,ST25,ST40,LI11 RN12,RN10,RN6,RN5,RN4,SP15,ST25,ST26,ST24SP13,SP14,SP15,ST29,ST25,ST24,ST21,RN24 Individualizationtreatment ST21,ST25,RN6,ST40 GB26,ST25,SP15,RN12,RN6 Individualizationtreatment RN13,RN12,ST36,ST25 RN12,RN10,RN4,RN6,ST25,SP15,ST24,ST28ST25,RN4,RN9,ST36,ST40,SP6ST37,ST40,SP6,SP4,ST34,ST25,BL20,BL21,BL25BL25,ST25,BL21,RN12,BL27,RN4,ST37,ST40,SP9RN12,LR13,ST25,RN4,SP15,ST37,ST40 RN9,RN7,ST25,ST40
L
No.inACE/Ct. 150/90 40/40 40/40 23/22 65/64 45/44 53/53 36/36 30/21 41/41 72/68 27/28 40/40 32/32 48/48 35/35 22/22 60/30
Firstauthor,yearCao2006[32]Chen2007[33]Chen2014[34]Ding2006[35]Ding2006[36]Jin2009[37]Li2009[38]Li2007[39]Li2006[40]Li2014[41]Li2009[42]Liu2008[43]Liu2008[44]Liu2007[45]Meng2005[46]Ruan2009[47]Tian2014[48]Wang2001[49]
Evidence-BasedComplementaryandAlternativeMedicine 5
eeffects Ct. NR NR NR NR NR NR NR NR NR NR NR NR headache,drymouth,anorexia,insomnia,constipation,rapidheartbeat,mildhighbloodpressure gastrointestinal𝑛=6discomfort()
d
Si ousnsand=1)
ACE NR NR NR NR NR NR NR NR NR NR NR NR NR bcutanenduratio=5),red𝑛ollen(
sui𝑛(sw
Ct.) effect / IR / / / / / / / / / / /
s o
u N
s
r
e
v
E
Outcome(AC Withbenefits IR / / D,BMI,WHR,IR BMI,IR IR MI,WC,HC,OD,FP,IR / C,BW,BMI,IR IR / appetite / W,BMI,WHR
O B W B
1:Continued. FrequencyofCt.(totaltimes) 1per1day(30) 1per3days(30) 1per1day(56) 1per2days(42) >1per1day(90) 6per1week(30) 5per1week(60) 1per1day(30) notclear 1per1day(30) 1per2days(36) 1per2days(45) 10mgper1time,1timeper1day,total56days 0.7gper1time,3timesper1day,total8weeks
e
Tabl FrequencyofCE(totaltimes) per1weeks(4) per15days(6) per1weeks(8) per2weeks(6) 1per15days(6–10) per15days(4) per10–14days(6–8) per1week(4) per1week(8) per15days(3) per15days(6) per10days(3) per20days(6) per1week(8)
A 1 1 1 1 1 1 1 1 1 1 1 1 1
)
Ct. ne o)
ntion pesof MA MA MA MA MA MA MA MA MA MA MA MA drugutrami drughiBiTu
erve Ty (sib (Z
nt
I AcupointsofACE ST37,ST40,SP6,SP4,ST34,ST25,BL20,BL21,BL25 ST25,ST36,RN13,RN12 AShi,RN12,ST25,GB26 BL18,BL20,BL23,ST40,SP6,ST36,RN12,RN10,ST25,ST29,RN4,EX-CA1,SP9ST25,ST40,ST36,SP6,BL21,BL20,BL25,ST28RN12,ST34,RN9,RN4,ST25,SP15,LI11,SJ6,ST44,ST40,ST37,SP6,SP9RN12,ST25,RN6,SP15,ST28,SP14,ST24,ST40,SP6RN12,RN9,RN6,RN4,ST25,SP15,ST36,SP9ST25,RN12,LI11,SP9,ST40,LR3,ST29,RN10,RN3,SJ6 LI11,RN12,ST25,RN6 RN12,ST25,RN6,ST37 RN12,ST25,RN6,ST37 RN12,RN4,ST25,AShi RN12,RN9,ST25,BL25,ST34,SP4
No.inCE/Ct. 30/30 36/36 25/23 30/30 35/33 30/30 25/25 27/26 30/30 78/47 30/30 30/30 56/70 32/31
A
Firstauthor,yearWang2006[50]Xia2014[51]Xiong2006[52] Xu2014[53] Yan2007[54] Yang2011[55] Yao2014[56]Yin2007[57]Zhang2014[58]Zhang2007[59]Zhang2006[60]Zhang2008[61] Nie2007[62] Cong2007[63]
6 Evidence-BasedComplementaryandAlternativeMedicine
e,L:
agD
ntH
ercence,
5 pe
Ct. 𝑛= NR NR NR NR NR NR NR NR NR NR P:fatumfer
Sideeffects umference,FC:shankcirc
cS
ACE / NR NR NR NR NR NR NR NR NR NR chestcirglycerol,
CC:acyl
x,tri
1:Continued. Outcome(ACEversusCt.)FrequencyofCt.WithbenefitsNoeffect(totaltimes)10mgper1time,//1timeper1day,total56days notclearIR,leptin,insulin/ 3per1week(24)WHR,BW,TC,TG/ 3per1week(24)// BW,IR,BMI,3per1week(24)medicalcostWC,HC,WHRIR,BW,BMI,WC,/3per1week(24)HC,WHR 1pre1week(8)IR/ IR,BW,BMI,HC,1per15days(6)CC,WC,HC,/THC,SC2-3per1weekIR,WC/(8–12) 3per1week(20)WHR,BMI,/ IR,BW,BMI,WC,1per1-2day(s)/WHR,HAMD,(15)HAMA,PSQI R:improvementrate,BW:bodyweight,BMI:bodymassindeasalmetabolism,OD:obesitydegree,TC:totalcholesterol,TG:QI:Pittsburghsleepqualityindex.
Table erventionFrequencyofTypesofCt.ACE(totaltimes) drug1per15days(6)(sibutramine) drug1per1week(4)(metformin) EA3per1week(24) EA1per2weeks(4) EA1per1week(4) EA1per1week(8) Sham1per1week(8) Sham1per15days(6) 1per15–20daysCupping(4) EA1per1day(60) EA1per15days(3) EA:electroacupuncture,Ct.:control,Iumference,WHR:waisthiprate,BM:bHAMA:Hamiltonanxietyscale,andPS
FirstIntauthor,No.inAcupointsofACEyearACE/Ct.RN12,ST25,SP15,RN6,RN4,Zhang35/34RN3,LA14,RN9,ST40,SP6,2010[64]GB30,BL37,LI11Li2014GB26,GB27,GB28,RN4,KI13,30/30[65]ST28,BL52Zhang40/40RN10,RN5,ST25,ST23,ST272008[66]RN13,RN12,RN10,RN7,RN9,RN4,RN6,ST25,ST24,ST26,Zhu201425/25SP15,SP14,GB26,GB27,LI14,[67]SJ13,LI4,LI11,GB31,GB32,ST34,ST36,ST37,ST40,SP6,SP9HuangRN12,ST25,SP15,RN9,RN6,30/302011[68]RN4,ST36,AshiST21,ST25,ST28,Ashi,RN12,Ruan30/30RN9,ST27,GB26,Ashi2010[69]RN12,RN10,RN6,RN4,ST40,Guo68/65SP15,ST24,ST362009[70] ST24,ST28,GB26,SP14,ST21,Jia201420/20ST25,ST40[71] RN12,ST25,RN4,RN6,ST36,Hou201440/40ST40[72]ST25,RN12,RN4,BL25,BL20,Pan2009ST24,SP15,RN9,RN7,BL21,40/40[73]BL26,ST26,GB26,RN11,RN6,BL23,BL28 TangRN12,ST25,RN6,RN4,ST34,33/322009[74]ST36,SP4,BL15,BL20 ACE:acupointcatgutembedding,MA:manualacupuncture,THC:thighcircumference,BM:basicmetabolism,HC:hipcirchigh-densitylipoprotein,HAMD:Hamiltondepressionscale,
Evidence-BasedComplementaryandAlternativeMedicine 7
291CNKI was presented optically by the asymmetry of funnel plot
135CBM (Figure6).
248Wanfang Forthereductionofbodyweight,asshowninFigure7,
237VIP themergedresultsof12studies[33,34,39–41,45,51,56–58,
5PubMed 60,61]demonstratednovarianceinthetwogroupsusinga
10EBSCO fixed effects model (MD = 1.14, 95% CI = −0.12∼2.40, 𝑝 =
7Springer 0.08). No heterogeneity (𝐼2 = 6%, Chi2 test 𝑝 = 0.39) and
8Cochrane Library theirpublicationbiaswerefoundinFigure8.
13Embase
3Web of Science
1ICTRP 3.3.3. Reduction of WC and HC. The combined reduction
of WC from 9 trials [39–41, 47, 53, 56, 58, 60, 61] was
of significant difference between the two groups (MD =
572 duplications
2.20, 95% CI = 0.62∼3.79, 𝑝 = 0.007), and no significant
97reviews heterogeneity was found (𝐼2 = 0%, Chi2 test 𝑝 = 0.89),
70case reports asshowninFigure9.However,thetherapyofACEwasnot
386 articles 46combining therapy superior to MA according to the pooled outcome of HC
70TCM theory discussion (MD = 0.47, 95% CI = 0.99∼1.94, 𝑝 = 0.53); no significant
23animal mechanism heterogeneity (𝐼2 = 0%, Chi2 test 𝑝 = 0.72) was shown in
26other diseases Figure10.
3different styles of catgut embedding
4conference summary and others
1in ICTRP without results 3.4.Comparison2:ACEversusDrug
3.4.1.FrequencyofImprovement. Twotrials[62,64]reported
47 articles 2 not randomized
the frequency of improvement and there was no difference
2 redundant publications
between ACE group and drug group (OR = 1.14, 95% CI =
0.33∼3.90,𝑝=0.84).Nosignificantheterogeneitywastested
43 articles
amongtheresults(𝐼2 =0%,Chi2test𝑝=0.65)(Figure11).
(1) Reduction of BMI and Body Weight. Four trials [62–65]
30catgut embedding versus acupuncture
reported the reduction of BMI, and the combined results
4catgut embedding versus drugs
indicatednosignificantdifferencebetweenthetwointerven-
5catgut embedding versus electroacupuncture (1 reutilization) tions (OR = 0.83, 95% CI = −0.25∼1.91, 𝑝 = 0.84). It was
2catgut embedding versus sham catgut embedding considerablyheterogeneousamongthe4studies(𝐼2 = 77%,
14ccaattgguutt eemmbbeeddddiinngg +ve crosunst rcoul pvpeirnsugs control (2reutilizations) Chi2test𝑝=0.004)andmightbecausedbythedifferencein
drugsorfrequencyofACE(Figure12).
Figure 1: Flow diagram or the number of studies included and Thepooledresultsof3studies[62–64]showedthatthere
excluded. wasnosignificantdifferenceaboutbodyweightlossbetween
the intervention of ACE and drugs (MD = 1.26, 95% CI =
−0.77∼3.30,𝑝=0.22).Therewasnosignificantheterogeneity
between the studies (𝐼2 = 15%, Chi2 test 𝑝 = 0.31)
and all of them evaluated the frequency of improvement. (Figure13).
The heterogeneity within each trial was low (𝐼2 = 42%,
Chi2 test 𝑝 = 0.01), and fixed effect model was applied to (2) Reduction of WC and HC. For the outcome of WC
calculatetheincorporateddata.Thepooledoutcomesshowed reduction, there were 2 trials [62, 64] reported and no
more improvement of obesity participants in ACE groups significantdifferencebytheircombination(MD=1.20,95%
than in MA groups (OR = 2.01, 95% CI = 1.58∼2.56, 𝑝 < CI = −0.54∼2.94, 𝑝 = 0.18). There was no heterogeneity
0.01)(Figure3).Thesymmetrywasshowninfunnelplotand betweentheresults(𝐼2 =0%,Chi2test𝑝=0.58)(Figure14).
indicatedlowpublicationbias(Figure4). Onetrial[62]reportedthedecreaseofHC,andnodifference
between the two groups was shown (MD = 0.26, 95% CI =
−2.65∼3.17,𝑝=0.86)(Figure15).
3.3.2.ReductionofBMIandBodyWeight. 12studiesreported
thedeclineofBMI[33,39–42,51,53,54,57,58,60,61],and
no difference was found between the two groups of catgut
3.5.Comparison3:ACEversusEA
embedding versus MA (MD = 0.56, 95% CI = −0.36∼1.49,
𝑝 = 0.23) tested by random effect model for their statistic 3.5.1. Frequency of Improvement. There was no statistical
heterogeneity(𝐼2 = 69%,Chi2 test𝑝 = 0.0002)whichmay difference in frequency of improvement according to the
be caused by the differences of frequency of intervention, combined results of 4 studies [58, 67–69] comparing the
manipulations, and participants (Figure5). Publication bias ACE with EA (OR = 1.73, 95% CI = 0.77∼3.92, 𝑝 = 0.19).
8 Evidence-BasedComplementaryandAlternativeMedicine
as)
bi
e
c
n
a
Random sequence generation (selection bias) Allocation concealment (selection bias) Blinding of participants and personnel (perform Blinding of outcome assessment (detection bias) Incomplete outcome data (attrition bias) Selective reporting (reporting bias) Other biases
Cao 2006 +
Chen et al. 2007 + +
Chen et al. 2014 + +
Cong et al. 2007 − +
Ding and Ma 2006 + +
Ding et al. 2006a +
Guo et al. 2009 + + +
Hou et al. 2014 + +
Huang and Pan 2011 + + +
Jia et al. 2014 +
Jin 2009 +
Li and Ge 2006 +
Li and Tian 2007 +
Li and Wu 2009 − +
Li and Lu 2009a +
Li et al. 2014 + +
Li et al. 2014a +
Liu and Xun 2007 +
Liu and Li 2008 +
Liu and Su 2008a − +
Meng and Chen 2005 + +
Nie 2007 +
Pan et al. 2009 +
Ruan and Lu 2009 +
Ruan et al. 2010 +
Tang et al. 2009 − +
Tian and He 2014 + +
Wang et al. 2001 +
Wang 2006 + + Random sequence generation (selection bias)
Xia 2014 − + Allocation concealment (selection bias)
Xiong and Zuo 2006 + Blinding of participants and personnel (performance bias)
Xu 2014 + + Blinding of outcome assessment (detection bias)
Yan 2007 +
Incomplete outcome data (attrition bias)
Yang et al. 2011 +
Selective reporting (reporting bias)
Yao 2014 +
Yin and Huo 2007 − + Other biases
Zhang and Fu 2006 + +
0 25 50 75 100
Zhang 2007 +
Zhang et al. 2008 + + (%)
Zhang et al. 2008a +
Zhang et al. 2010 + Low risk of bias
Zhang et al. 2014 + Unclear risk of bias
Zhu and Xu 2014 + High risk of bias
Figure2:Riskofbiassummaryandgraph.
Significant heterogeneity was not tested among the results heterogeneitybetweentheresultswasshown(𝐼2 =79%,Chi2
(𝐼2 =28%,Chi2test𝑝=0.25)(Figure16). test𝑝=0.002)andmaybeexplainedthedifferenceofpatients
oracupointprescriptions(Figure17).
3.5.2.ReductionofBMIandBodyWeight. Thepooledresults Significantdifferenceofbodyweightloss(MD=1.79,95%
of4trials[58,67–69]releasedtheideathatACEtreatment CI=0.777∼2.81,𝑝=0.0006)wastestedbythepooledresults
was not better than EA statistically in reduction of BMI of4trials[58,66,68,69].Therewasnoobviousheterogeneity
(MD = 0.79, 95% CI = −0.42∼2.00, 𝑝 = 0.20). Substantial amongtheresults(𝐼2 =0%,Chi2test𝑝=0.98)(Figure18).
Evidence-BasedComplementaryandAlternativeMedicine 9
Acupoint catgut embedding Manual acupuncture Odds ratio Odds ratio
Study or subgroup Weight
Events Total Events Total M-H, fixed, 95% CI M-H, fixed, 95% CI
Cao 2006 141 150 72 90 5.7% 3.92 [1.68, 9.15]
Chen et al. 2007 36 40 35 40 3.7% 1.29 [0.32, 5.19]
Chen et al. 2014 38 40 28 40 1.5% 8.14 [1.69, 39.32]
Ding and Ma 2006 20 23 15 22 2.1% 3.11 [0.69, 14.07]
Ding et al. 2006a 59 65 54 64 5.3% 1.82 [0.62, 5.35]
Jin 2009 44 45 39 44 0.9% 5.64 [0.63, 50.40]
Li and Ge 2006 28 30 20 21 1.7% 0.70 [0.06, 8.26]
Li and Tian 2007 33 36 34 36 3.0% 0.65 [0.10, 4.12]
Li and Wu 2009 50 53 42 53 2.5% 4.37 [1.14, 16.69]
Li and Lu 2009a 63 72 62 68 8.4% 0.68 [0.23, 2.02]
Li et al. 2014 30 41 29 41 8.2% 1.13 [0.43, 2.96]
Liu and Xun 2007 29 32 28 32 2.8% 1.38 [0.28, 6.73]
Liu and Li 2008 40 40 40 40 Not estimable
Liu and Su 2008a 18 27 23 28 8.0% 0.43 [0.12, 1.53]
Meng and Chen 2005 47 48 42 48 0.9% 6.71 [0.78, 58.08]
Ruan and Lu 2009 33 35 30 35 1.8% 2.75 [0.50, 15.25]
Tian and He 2014 19 22 14 22 2.0% 3.62 [0.81, 16.15]
Wang et al. 2001 59 60 27 30 0.6% 6.56 [0.65, 65.95]
Wang 2006 28 30 22 30 1.6% 5.09 [0.98, 26.43]
Xia 2014 20 36 24 36 11.3% 0.63 [0.24, 1.62]
Xiong and Zuo 2006 23 25 22 23 1.9% 0.52 [0.04, 6.18]
Xu 2014 23 30 27 30 6.7% 0.37 [0.08, 1.58]
Yan 2007 32 35 27 33 2.5% 2.37 [0.54, 10.39]
Yang et al. 2011 29 30 21 30 0.7% 12.43 [1.46, 105.74]
Yao 2014 22 25 19 25 2.4% 2.32 [0.51, 10.54]
Yin and Huo 2007 21 27 19 26 4.6% 1.29 [0.37, 4.52]
Zhang and Fu 2006 29 31 26 30 1.8% 2.23 [0.38, 13.20]
Zhang 2007 74 78 37 47 2.5% 5.00 [1.47, 17.02]
Zhang et al. 2008 29 32 26 30 2.7% 1.49 [0.30, 7.28]
Zhang et al. 2014 25 30 12 30 2.1% 7.50 [2.24, 25.06]
Total (95% CI) 1268 1124 100.0% 2.01 [1.58, 2.56]
Total events 1142 916
Heterogeneity:𝜒2=48.03,df=28(p=0.01);I2=42%
Test for overall effect:Z=5.66(p<0.00001) 0.002 0.1 1 10 500
Manual acupuncture Acupoint catgut embedding
Figure3:ForestfigureofthefrequencyofimprovementinthecomparisonofACEversusMA.
0
0.5
R])
O
g[ 1
o
E (l
S 1.5
2
0.002 0.1 1 10 500
OR
Figure4:FunnelplotsofthefrequencyofimprovementinthecomparisonofACEversusMA.
3.5.3. Reduction of WC and HC. Three studies [58, 68, shown,maybecausedbydifferencesofpatientsoracupoint
69] reported no difference in WC loss between the two prescriptions(Figure20).
interventions(MD=1.89,95%CI=−0.79∼4.57,𝑝 = 0.17),
andnoheterogeneitywasobserved(𝐼2 = 0%,Chi2 test𝑝 =
0.49)(Figure19).Twostudies[68,69]indicatedtherewasno 3.6.Comparison4:ACEversusSham
differenceinHClossbetweenthetwointerventions(MD= 3.6.1.FrequencyofImprovement. Thepooledresultsof2trials
4.38,95%CI=−0.95∼4.72,𝑝=0.011),andheterogeneitywas [70,71]showedthereweresignificantdifferences(OR=9.13,
10 Evidence-BasedComplementaryandAlternativeMedicine
Acupoint catgut embedding Manual acupuncture Mean difference Mean difference
Study or subgroup Weight
Mean SD Total Mean SD Total IV, random, 95% CI IV, random, 95% CI
Chen et al. 2007 6.2 4.1698 40 7.3 4.41928 40 8.3% −1.10 [−2.98, 0.78]
Li and Ge 2006 3.81 3.89189 30 3.99 3.41425 21 7.9% −0.18 [−2.20, 1.84]
Li and Tian 2007 6.98 4.19175 36 6.04 4.88307 36 7.6% 0.94 [−1.16, 3.04]
Li and Wu 2009 2.27 3.30079 72 1.97 3.34072 68 10.7% 0.30 [−0.80, 1.40]
Li et al. 2014 1.22 4.03546 41 1.33 3.4689 41 9.0% −0.11 [−1.74, 1.52]
Xia 2014 2.9 4.50081 36 4.36 5.18819 36 7.2% −1.46 [−3.70, 0.78]
Xu 2014 7.11 3.25374 30 2.5 3.28114 30 9.0% 4.61 [2.96, 6.26]
Yan 2007 4.09 4.25226 35 2.45 4.23395 33 7.9% 1.64 [−0.38, 3.66]
Yin and Huo 2007 0.7 3.45987 27 0.92 3.32892 26 8.4% −0.22 [−2.05, 1.61]
Zhang and Fu 2006 3.3 7.54785 31 2.4 4.272 30 5.3% 0.90 [−2.17, 3.97]
Zhang et al. 2008 2.6 3.97366 32 3.1 2.93087 30 8.7% −0.50 [−2.23, 1.23]
Zhang et al. 2014 3.88 2.43039 30 2.37 2.70355 30 10.1% 1.51 [0.21, 2.81]
Total (95% CI) 440 421 100.0% 0.56 [−0.36, 1.49]
Heterogeneity:𝜏2=1.77;𝜒2=35.89,df=11(p=0.0002);I2=69%
Test for overall effect:Z=1.19(p=0.23) −4 −2 0 2 4
Manual acupuncture Acupoint catgut embedding
Figure5:ForestfigureofBMIlossinthecomparisonofACEversusMA.
0
0.5
D)
M 1
E (
S
1.5
2
−4 −2 0 2 4
MD
Figure6:FunnelplotsofBMIlossinthecomparisonofACEversusMA.
Acupoint catgut embedding Manual acupuncture Mean difference Mean difference
Study or subgroup Weight
Mean SD Total Mean SD Total IV, fixed, 95% CI IV, fixed, 95% CI
Chen et al. 2007 5.21 5.56015 40 4.91 6.08224 40 24.4% 0.30 [−2.25, 2.85]
Chen et al. 2014 7.41 8.04679 40 4.74 8.04159 40 12.8% 2.67 [−0.86, 6.20]
Li and Ge 2006 7.54 7.37871 30 6.78 7.07104 21 9.9% 0.76 [−3.25, 4.77]
Li and Tian 2007 8.5 7.99567 36 8.7 7.90187 36 11.8% −0.20 [−3.87, 3.47]
Li et al. 2014 3.36 15.9564 41 3.49 12.8534 41 4.1% −0.13 [−6.40, 6.14]
Liu and Xun 2007 4.8 12.1224 32 4.1 11.6396 32 4.7% 0.70 [−5.12, 6.52]
Xia 2014 3.67 10.1656 36 7.34 9.98714 36 7.4% −3.67 [−8.33, 0.99]
Yao 2014 12.71 10.7402 25 7.5 9.7651 25 4.9% 5.21 [−0.48, 10.90]
Yin and Huo 2007 2.01 12.404 27 2.38 12.5356 26 3.5% −0.37 [−7.09, 6.35]
Zhang and Fu 2006 7.6 12.4012 31 3.6 9.85951 30 5.1% 4.00 [−1.61, 9.61]
Zhang et al. 2008 6.5 14.8091 32 3.4 12.7644 30 3.4% 3.10 [−3.77, 9.97]
Zhang et al. 2014 10.04 8.87957 30 5.49 8.77646 30 8.0% 4.55 [0.08, 9.02]
Total (95% CI) 400 387 100.0% 1.14 [−0.12, 2.40]
Heterogeneity:𝜒2=11.67,df=11(p=0.39);I2=6%
Test for overall effect:Z=1.77(p=0.08) −10 −5 0 5 10
Manual acupunctureAcupoint catgut embedding
Figure7:ForestfigureofbodyweightlossinthecomparisonofACEversusMA.
95%CI=4.30∼11.36,𝑝 < 0.00001)intheimprovementrate 3.6.2. Reduction of BMI and Body Weight. One study [71]
comparingACEwithshaminwhichtheneedlinginstrument reportedtheBMIloss,andnosignificanteffectwasobserved
wasjustpenetratedbutthecatgutwasnotimplanted.There (MD = 1.63, 95% CI = −0.19∼3.45, 𝑝 < 0.08) (Figure22).
wasnoheterogeneityamongtheresults(𝐼2 = 32%,Chi2test The result of body weight loss was of significant difference
𝑝=0.22)(Figure21). (MD=3.10,95%CI=0.20∼6.00,𝑝 < 0.04)betweenthetwo