Acupoint Catgut Embedding Therapy for Abdominal Obesity Treatment

This study explores acupoint catgut embedding therapy for obesity, covering patient management, material preparation, acupoint selection, surgery, and post-operative care.

As the global economy grows and living standards improve, the rise in overweight and obese individuals poses a significant public health challenge. This trend is predominantly linked to lifestyle changes and poor dietary habits, resulting in increased abdominal obesity characterized by fat accumulation in the abdominal region and associated symptoms such as indigestion, constipation, and fatigue. Acupoint embedding therapy uses absorbable sutures inserted into specific acupoints for continuous stimulation, aiding in the treatment of abdominal obesity, metabolic issues, and digestive disorders. Its main goals are to regulate metabolism, improve digestion, and reduce fat. This paper offers a thorough exploration of the comprehensive management of thread-embedding acupuncture for obesity treatment. It meticulously outlines critical aspects of patient management and material preparation and provides precise guidance on acupoint selection, surgical procedures, and postoperative care. This structured treatment protocol aims to ensure procedural safety and efficacy, thereby optimizing clinical outcomes for patients with abdominal obesity and ultimately improving their overall quality of life.

The prevalence of metabolic syndrome has contributed to a global increase in overweight and obesity, affecting approximately half of the population and imposing significant socioeconomic burdens¹. Abdominal obesity, also known as central or visceral obesity, is characterized by the accumulation of fat primarily around the abdominal area. Apart from its impact on appearance, obesity can affect organ function due to the buildup of visceral fat². Studies indicate that abdominal obesity significantly increases the risk of cardiovascular diseases such as coronary artery disease, hypertension, and stroke^3,4,5. Visceral adipose tissue releases cytokines that promote inflammation, contributing to conditions like atherosclerosis and thrombosis⁶. Furthermore, obesity induces dysfunction in visceral adipose tissue, leading to insulin resistance and type 2 diabetes^7,8,9. In China, the availability of approved medications for weight loss is limited, making the selection of a safe, effective, and easily implementable weight loss regimen a persistent clinical challenge¹⁰.

Traditional Chinese medicine has a longstanding history of understanding and treating obesity, often associating it with the concept of phlegm dampness¹¹. Traditional Chinese medicine (TCM) usually adopts herbs to strengthen the spleen as well as dispel dampness and acupuncture for the treatment of obesity. These practices have achieved significant results in reducing body weight, decreasing waist circumference, and lowering blood lipids, etc. Acupoint catgut embedding, developed in the 1950s, is an innovative therapy that evolved from the acupuncture technique known as the retained needle method¹². This approach utilizes traditional Chinese medicine principles and meridian theory by inserting absorbable surgical sutures into acupoints, providing sustained stimulation that effectively regulates organ functions for a longer duration than a single acupuncture session. It is widely used in the clinical management of chronic disorders such as obesity, asthma, and insomnia^13,14,15.

In recent years, acupoint catgut embedding has gained prominence in clinical and experimental research on abdominal obesity ^{16,17,18,19,20}. Studies indicate that this technique effectively modulates metabolic functions, enhances fat breakdown, and promotes weight and lipid reduction²¹. Additionally, it has been shown to suppress gastrointestinal peristalsis and reduce gastric acid secretion, thereby alleviating hunger and aiding in weight loss¹⁶. The Multidisciplinary clinical consensus on the diagnosis and treatment of obesity²² recognizes acupoint catgut embedding as a significant adjunctive therapy for obesity. However, patient awareness of this technique remains limited. This protocol provides comprehensive guidelines on patient evaluation, material preparation, acupoint selection, procedural steps, and postoperative care. These measures are essential for ensuring the safety and efficacy of catgut embedding therapy, offering a practical approach to reducing weight, waist circumference, and clinical symptoms in patients with abdominal obesity. The purpose of this protocol is to reduce waist circumference to combat abdominal obesity and weight control by acupoint catgut embedding.

The study received approval from the ethics committee of Zhejiang Hospital of Integrated Traditional Chinese and Western Medicine (2024-058). According to the World Health Organization's obesity diagnostic criteria²³, overweight is defined as BMI ≥24 kg/m², and obesity is classified as BMI ≥28 kg/m². The guidelines established by the Chinese Joint Committee for Developing Chinese Guidelines²⁴ define abdominal obesity as waist circumference ≥85 cm in females and ≥90 cm in males. Traditional Chinese Medicine (TCM) operations adhere to the Criteria of Diagnosis and Therapeutic Effect of Diseases and Syndromes in Traditional Chinese Medicine²⁵. This retrospective study enrolled 8 patients who underwent an acupoint thread embedding for weight loss. Informed consent from the patients was waived by the Ethics Committee of Zhejiang Hospital of Integrated Traditional Chinese and Western Medicine. Details regarding all materials used in the protocol are available in Figure 1.

1. Patient assessment

1. Inclusion criteria: 1) Select patients diagnosed with abdominal obesity as per established diagnostic guidelines^23,24,25. 2) Patients between 20 and 70 years of age. 3) Patients who received 2 months of treatment. Fully inform patients about surgical risks and precautions. Ensure the skin around the operated knee joint remains intact.
2. Exclusion criteria: Exclude patients with the following conditions: Pregnant women, children, and other groups contraindicated for surgery; patients with chronic or malignant diseases; individuals with a history of needle sickness or allergies to sterile absorbable suture thread. Evaluate the patient's suitability for thread embedding prior to surgery and ensure that the skin around the surgery is intact and undamaged.

2. Pre-therapy preparation of the operator

1. Conduct a comprehensive assessment of the patient's condition. Perform preoperative evaluations, including liver and kidney function tests, coagulation profiles, and infectious disease screenings. Obtain a detailed history of bleeding and other relevant medical histories prior to treatment initiation.
2. Perform an electrocardiogram examination for patients over 40 years old. Use a body composition analyzer to measure body components and obtain data on weight, body fat, visceral fat, and waist circumference.
3. Ask patients to void before the start of surgery. Instruct patients to report any pain during the procedure. Advise patients to bathe one day before surgery, as the incision site should remain dry for 3 days post-operation. Avoid surgery on an empty stomach.

3. Operational procedure

1. Body position selection: Select the supine position for the operation, fully exposing the acupoints. Anesthesia is not required since there is no pain or minimal pain.
2. Acupoint selection: Locate the following acupoints according to Meridians and Acupoints²⁶ (Figure 2A): Guanyuan(RN4), Qihai (RN6), Xiawan(RN10), Zhongwan(RN12), Tianshu (ST25), Daheng (SP15). Perform point identification on the body as described below. Consider the width of the patient's thumb interphalangeal joint as 1 F-cun (Figure 2B).
   1. Guanyuan (RN4): Locate this in the lower abdomen, on the anterior midline, 3 cun below the center of the navel (equivalent to the width of 4 fingers).
   2. Qihai (RN6): Identify this as the point located in the lower abdomen, on the anterior midline, 1.5 cun below the center of the navel.
   3. Xiawan (RN10): Locate this in the upper abdomen, on the anterior midline, 2 cun above the center of the navel.
   4. Zhongwan (RN12): Locate this in the upper abdomen, on the anterior midline, 4 cun above the center of the navel.
   5. Tianshu (ST25): Locate this point on the abdomen, level with the center of the navel, 2 cun lateral to the anterior midline.
   6. Daheng (SP15): Locate this point on the abdomen, level with the center of the navel, 4 cun lateral to the anterior midline.
3. Sterility requirements: Strictly adhere to surgical aseptic techniques throughout the procedure. Disinfect the skin three times with single-use cotton swabs dipped in 7.5% povidone-iodine solution, moving outward from the center of the acupoint, covering at least 3 cm x 3 cm.
4. Perform the operation as described below.
   1. Apply lidocaine hydrochloride gel evenly to the surgical site. Soak a sterile 4-0 absorbable suture (2 cm in length) in physiological saline to make it soft. Clamp absorbable suture and position it at the tip of a sterile disposable needle that corresponds to the size of the thread, ensuring the thread maintains equal length inside and outside the needle. Cut the absorbable suture to the appropriate length using sterile surgical scissors.
   2. Utilize the left thumb and forefinger to tighten or pinch the skin around the acupuncture point (Figure 2C). Grasp the needle with the right hand, maintaining a 30° angle to the skin surface, and swiftly insert it through the skin. Ensure the thread folds in half at the point where the needle tip contacts the skin.
   3. Swiftly pass the needle through the skin, pressing the thread to form a fold at the needle tip. Ensure the thread outside the needle hole reaches the acupuncture point, and confirm the patient's experience of soreness and distension, indicating needle sensation or obtaining qi.
   4. Rotate the needle body while retracting it to embed the sterile absorbable suture into the subcutaneous skin or muscle layer at the acupuncture point. Press a sterile dry cotton ball around the needle hole with the left thumb and index finger during needle withdrawal. Use the right hand to gently twist and slowly lift the needle to the subcutaneous level before fully withdrawing it.
   5. Ensure that the sterile absorbable suture is implanted in the subcutaneous tissue or muscle, with the ends not exposed. Cover the puncture point with a surgical gauze dressing. Proceed to the next acupuncture point.

4. Postoperative care

1. Instruct the patient to rest for a while and observe any postoperative reactions, after completing all acupuncture point procedures.
2. Instruct the patient to keep the needle holes dry and clean to prevent infection and seek medical attention promptly if the patient feels unwell. Avoid getting the surgical area wet for 3 days post-operation.
   NOTE: Since the sutures embedded in the acupuncture points are absorbable, subsequent procedures can simply place new sutures in the same locations as the previous ones.
3. Administer the treatment every 2 weeks, with one course lasting 2 months.

5. Anthropometric assessment

1. Measure height, weight, and body composition using digital scales with bioimpedance analysis. Ask the patient to step onto the device and place bare feet on the foot electrodes, ensuring contact. Grip the hand electrodes and extend the arms to the sides until the measurement is complete.
2. Take measurements before treatment and after 2 months of treatment.

6. Statistical analysis

1. Use Student's t or Mann-Whitney tests to compare continuous variables expressed as the mean ± standard deviation (SD). Statistical tests were performed two-sidedly, and p < 0.05 was considered statistically significant.

A total of 8 abdominally obese patients meeting diagnostic criteria underwent acupoint thread embedding therapy in this study. Each patient underwent a total of 4 sessions of acupoint embedding therapy over a 2 month period. Standardized assessments of body weight, BMI, waist circumference, body fat, and visceral fat area were conducted using a human body composition analysis instrument before and after treatment. Following one treatment course, statistically significant reductions were observed in weight (81.4 ± 7.6 kg to 75.9 ± 7.0 kg), BMI (28.7 ± 2.5 kg/m² to 26.8 ± 1.9 kg/m²), waist circumference (98.1 ± 5.2 cm to 90.1 ± 5.0 cm), body fat (29.1 ± 4.6 kg to 25.5 ± 5.4 kg), and visceral fat area (143.9 ± 25.0 cm² to 124.4 ± 30.0 cm²; p < 0.05; Table 1). The result is consistent with previous findings which used the same method for weight loss^{12,16,17,19,27}.

In a case study, a 36-year-old female who had a history of postpartum weight gain over an 8-year period presented with a BMI of 32.4 kg/m² and a waist circumference of 108.5 cm, meeting the criteria for abdominal obesity. Following the exclusion of contraindications, the patient was educated on acupoint thread embedding and treatment goals. Upon admission, she reported loose stools, displayed a pale tongue with a white coating and teeth marks, and exhibited a slippery pulse. Traditional Chinese Medicine diagnosed her with obesity resulting from spleen deficiency and dampness accumulation based on these presenting symptoms. Treatment involved acupoint thread embedding at Guanyuan, Qihai, Zhongwan, Xiawan, and Fenglong points every 2 weeks for 2 months. Initial measurements indicated her weight was 77.5 kg, BMI was 26.1 kg/m², waist circumference was 92.7 cm, and body fat was 27.1 kg, with a visceral fat area of 131.4 cm². Following treatment, significant improvement in clinical symptoms was observed, with weight decreasing to 72.8 kg, BMI to 25.3 kg/m², waist circumference to 85.7 cm, body fat to 24 kg, and visceral fat area to 111.8 cm² (Table 2).

Figure 1: Operating materials. (A) Disposable gloves. (B) Aseptic Cotton Ball. (C) Surgical Scissors. (D) 0.9% Sodium Chloride Injection. (E) 7.5% povidone-iodine solution. (F) Lidocaine Hydrochloride Gel. (G) Single-use cotton swabs. (H) Surgical gauze dressing. (I) 4-0 Absorbable Suture. (J) Sterile Disposable Needle Please click here to view a larger version of this figure.

Figure 2: Acupuncture point selection and burrowing technique. (A) Location of Acupuncture Points. (B) Measurement diagram of 1 F-cun. Take the width of the interphalangeal joint of the patient's thumb as 1 F-cun. (C) Schematic diagram of the operation of acupoint burrowing. Grasp the needle with the right hand, maintaining a 30° angle to the skin surface, and swiftly insert it through the skin. Swiftly pass the needle through the skin, pressing the thread to form a fold at the needle tip. Ensure the thread outside the needle hole reaches the acupuncture point, and confirm the patient's experience of soreness and distension, indicating needle sensation or obtaining qi. Please click here to view a larger version of this figure.

Table 1: The effects of acupoint catgut embedding on patient weight, BMI, waist circumference, body fat, and visceral fat.

Table 2: Results of a typical case.

Acupoint embedding therapy, a traditional Chinese medical practice, involves the insertion of absorbable protein threads (e.g., catgut) into specific acupoints to stimulate meridians and achieve therapeutic effects²⁸. This therapy provides continuous stimulation to acupoints, regulating the endocrine system, boosting metabolism, suppressing appetite, improving digestion, and modulating the nervous system, thereby promoting weight loss²⁹. Targeting abdominal acupoints directly addresses areas of fat accumulation, facilitating localized fat breakdown and metabolism, which aids abdominal slimming³⁰.

Traditional acupoint embedding involves using a needle to insert thread into acupoints. The procedure utilizes the Folded Wire Rotation Technique invented by Yang et al., which involves folding the wire and leaving it directly in the acupoint, effectively solving the problem of wire clogging³¹. Despite its benefits, the method has limitations, such as varied patient responses and the need for repeated treatments due to temporary effects¹². Future advancements include the use of materials that adjust to stimulation automatically, enhancing effectiveness. A key step in this procedure is accurately locating the acupuncture point and swiftly inserting the needle, which helps minimize the patient's discomfort during insertion. To ensure safety and efficacy, acupoint embedding should be administered by trained practitioners who select acupoints accurately and maintain sterile procedures to prevent infections and other complications. Post-procedure care involves maintaining cleanliness and avoiding vigorous exercise and friction to prevent thread displacement or infection. Following medical guidance on post-operative care and regular follow-ups are essential. A balanced diet and moderate exercise regimen are recommended to optimize weight loss results and avoid high-calorie, high-fat diets.

Traditional methods for assessing waist circumference and visceral fat have notable limitations. Manual waist measurement is influenced by operator experience and measurement site, leading to inaccuracies³². Visceral fat assessment typically relies on imaging techniques such as CT or MRI, which, while precise, are limited by high costs, radiation exposure, and operational complexity³³. In contrast, body composition analyzers utilize bioelectrical impedance analysis (BIA) technology for a non-invasive, rapid, and accurate evaluation of visceral fat, eliminating radiation exposure and manual measurement errors³³. Additionally, these analyzers provide comprehensive data on total body fat and muscle distribution, aiding in the assessment of obesity risk and overall health. Therefore, this study employs a body composition analyzer to evaluate visceral fat and waist circumference.

Although acupoint embedding therapy for abdominal obesity leverages various physiological mechanisms effectively^16,34, factors such as individual variations, treatment duration, procedural risks, and costs should be carefully considered. Patients should be well-informed about their treatment options, consult healthcare professionals, and choose therapies that align with their individual needs. Given our current study's single-center design and limited sample size, future research endeavors to expand sample sizes to mitigate potential biases.

The authors have no conflicts of interest to declare.

This study was supported by the National Natural Science Foundation of China (No. T2341013), Hangzhou Red Cross Hospital Doctoral Research Start-up Fund Project(HHBJ2024001), Zhejiang Province Bureau of Health (No.2019KY350), Zhejiang Province Bureau of Traditional Chinese Medicine (No.2020ZA024), Zhejiang Key Modernization project of TCM (No.2022ZA004), and Key projects jointly built by Zhejiang Provincial Bureau and Provincial Government (No.WKJ-ZJ-2420).