Network Meta-Analysis of Acupoint Catgut Embedding in Treatment of Simple Obesity

Objective To evaluate the clinical efficacy of acupoint catgut embedding in the treatment of simple obesity through network meta-analysis. Methods PubMed, Cochrane, Embase, China National Knowledge Infrastructure (CNKI), Wanfang, and VIP database (VIP) were searched by using computer from 2011 to August 2021, and 35 RCT studies were retrieved. The quality of the literature was evaluated using the modified Jadad scoring table, and Stata 15.0 software was used for traditional meta-analysis and network meta-analysis. Results Thirty-five RCTs (3040 cases in total) were included. Acupoint embedding, acupuncture, electroacupuncture, TCM, acupoint embedding + acupuncture, acupoint embedding + exercise diet therapy, acupoint embedding + TCM, exercise diet therapy, acupoint embedding + moxibustion, and acupoint embedding + cupping were investigated in the studies. The results of network meta-analysis were as follows: in terms of total effective rate, acupoint catgut embedding was superior to acupuncture, electroacupuncture, and exercise diet therapy (P < 0.05); electroacupuncture, acupoint catgut embedding + acupuncture, acupoint catgut embedding + exercise diet therapy, acupoint catgut + TCM, acupoint catgut + moxibustion, and acupoint catgut + cupping were superior to acupuncture (P < 0.05); acupoint catgut + moxibustion was superior to electroacupuncture (P < 0.05); acupoint catgut + TCM, acupoint catgut + moxibustion, and acupoint catgut + cupping were superior to TCM treatment (P < 0.05); and electroacupuncture, acupoint catgut, acupoint catgut + acupuncture, acupoint catgut + exercise diet therapy, acupoint catgut + TCM, acupoint catgut embedding + moxibustion, and acupoint catgut embedding + cupping were superior to sports diet therapy (P < 0.05). Regarding weight loss, acupuncture treatment was superior to acupoint catgut embedding therapy (P < 0.05); acupoint catgut embedding + exercise diet therapy, acupoint catgut embedding + TCM, acupoint catgut embedding + moxibustion, and acupoint catgut embedding + cupping were superior to acupuncture and electroacupuncture treatment (P < 0.05); acupoint catgut embedding + exercise diet therapy, acupoint catgut embedding + TCM, and acupoint catgut embedding + moxibustion were superior to TCM treatment (P < 0.05); and acupoint catgut embedding, acupoint catgut embedding + acupuncture, catgut embedding + exercise diet therapy, acupoint catgut embedding + TCM, acupoint catgut embedding + moxibustion, and acupoint catgut embedding + cupping were superior to exercise diet therapy (P < 0.05). In terms of BMI reduction, acupoint catgut embedding + moxibustion and acupoint catgut embedding + cupping were more evident than acupuncture treatment (P < 0.05); and acupoint catgut embedding + moxibustion was more evident than electroacupuncture treatment (P < 0.05). Conclusion Acupoint catgut embedding and its combination with other therapies are the first choice for the treatment of simple obesity.


Introduction
Obesity is a chronic disease due to excessive accumulation or abnormal distribution of fat in the body [1]. Simple obesity is a kind of obesity caused by excessively more intake than consumption, excluding other diseases or medical factors [2]. Simple obesity is now an epidemic health problem, leading to higher incidence of other diseases. Excessive fat accumulation in the body is an important manifestation of obese people, resulting in a higher body mass index (BMI) than normal [3]. Over the past few decades, obesity has been considered to be the result of unbalanced intake and consumption of high-calorie diet. e survey shows that from 1993 to 2015, the prevalence of overweight and obesity, especially abdominal obesity, increased significantly among Chinese adults [4]. Obesity is the main risk factor of dyslipidemia and cardiovascular disease (CVD) [5]. At present, there are many treatment methods for obesity. Some literature studies show that acupoint catgut embedding and joint use with other therapies can improve the effective rate of treatment for simple obesity and reduce the BMI of patients [6].
is study used network meta-analysis to compare the efficacy of acupoint catgut embedding and its combination with other methods in the treatment of simple obesity, so as to provide some evidence support for clinical adjuvant therapy.

Methods. PubMed, Cochrane, Embase, China National
Knowledge Infrastructure (CNKI), Wanfang, and VIP Database (VIP) were selected as databases. "Catgut embedding at acupoints", "simple obesity", and "obesity" were Chinese and English search terms. e combination of subject headings and free words was the retrieval method. Title, abstract and keywords or Title, Abstract and Keywords were used as search entries. From the establishment of the database to August 2021 was the time for publication of the literature.

Inclusion and Exclusion Criteria.
e inclusion criteria of the literature were as follows: (1) patients who met the diagnostic criteria established by the Fifth National Obesity Academic Research Conference [7]; (2) type of study: RCTs were included according to the criteria in the Cochrane Collaborative Workbook; (3) intervention measures: the baseline data were complete, and at least two groups were included. Catgut embedding therapy was used in the test group, and the main indicators were drug response rate, body weight change, and BMI; and (4) languages were limited to Chinese and English. e exclusion criteria were as follows: (1) nonrandomized control; (2) literature with a sample size of less than 10 or repeated publications; (3) studies with incomplete data and lack of rigorous study design; and (4) studies with unclear efficacy outcome evaluation and analysis.

Literature Evaluation.
e quality of the literature was assessed using the risk of bias assessment tool provided by the Cochrane Collaboration. e following items were considered: (1) the generation of the random assignment plan, (2) whether the patients and doctors were blinded, (3) whether the outcome evaluation was blinded or not, (4) whether it was a hidden allocation scheme, (5) whether it was a selectively reported study result, (6) whether the result data were complete or not, and (7) whether there was other bias. e quality of the included literature was evaluated on a scale of 1 to 7 using the modified Jadad scale from the aspects of random sequence generation, randomization concealment, blinding, and complete follow-up. Scores 1-3 were considered low quality and 4-7 high quality.

Data Extraction.
According to the above principles, two researchers independently searched and screened the literature and evaluated the quality of the final included results using EndNote software. In case of any disagreement, the third researcher would join and make a decision.

Statistical
Processing. Body weight and BMI were numerical variables. e difference between the variables before and after treatment was used to calculate the standard deviation of the variable difference with the help of the correlation coefficient (R � 0.5), and 95% confidence intervals (CI) of the median and percentile of the difference were estimated. Effectiveness was count data, for which the odds ratio (OR) was used for statistical analysis, and with 95% CI were calculated. e heterogeneity analysis was performed using the I 2 value. If I 2 <50%, the heterogeneity was small and could be ignored, and the fixed effect model was used. If I 2 >50%, the heterogeneity was large, and the random effect model was used.
STATA15.0 software was used to draw the network evidence relationship diagram, forest plot, rank probability diagram, and funnel plot with corresponding statistics, and the consistency test was used to compare the ring consistency. In this study, the surface under the cumulative ranking curve (SUCRA) was used to calculate the cumulative ranking probability of each treatment regimen. A higher SUCRA value indicates more effective intervention.

Traditional Meta-Analysis Results.
Meta-analysis showed that the total effective rate of acupoint catgut embedding + TCM treatment, acupoint catgut embedding + moxibustion treatment, and acupoint catgut embedding + cupping treatment was higher than that of acupoint catgut embedding treatment alone with statistically significant differences. Acupoint catgut embedding and acupoint catgut embedding + acupuncture were superior to acupuncture treatment, and the differences were statistically significant. Acupoint catgut embedding + TCM treatment was more effective than TCM treatment with statistically significant differences. Acupoint catgut embedding was superior to electroacupuncture, and the difference was statistically significant; other direct comparisons showed no significant difference.
Meta-analysis results of weight loss showed that acupoint catgut embedding + TCM treatment, acupoint catgut embedding + moxibustion treatment, and acupoint catgut embedding + cupping treatment were superior to acupoint catgut embedding, and the difference was statistically significant. Acupoint catgut embedding was superior to acupuncture, and the difference was statistically significant. Acupoint catgut embedding + TCM treatment was superior to TCM treatment, and the difference was statistically significant. Other direct comparisons showed no statistically significant differences.
Meta-analysis results showed that BMI reduction by acupoint catgut embedding + TCM treatment, acupoint catgut embedding + moxibustion treatment, and acupoint catgut embedding + cupping treatment were more evident than that by acupoint catgut embedding treatment alone, acupoint embedding + TCM treatment was superior to TCM treatment, acupoint embedding treatment was superior to acupuncture, acupoint catgut embedding was superior to electroacupuncture, acupoint catgut embedding + exercise diet therapy was superior to exercise diet therapy, and there was no significant difference in other direct comparison results. e meta-analysis results are shown in Table 3.

Consistency Test.
e variable of the total effective rate of treatment contained 6 closed loops, the lower limit of the 95% CI of the 5 loop inconsistency factors (IFs) after the consistency test was 0, there was no obvious inconsistency, and the 95% lower limit of 1 closed loop IF was 0.16, failing to reach 0. Inconsistency was statistically significant, indicating inconsistency. e decrease in body mass involved 5 closed loops, the lower limit of the 95% CI of the discordance factor IF contained 0, and there was no significant discordance.  Evidence-Based Complementary and Alternative Medicine Evidence-Based Complementary and Alternative Medicine 5   Evidence-Based Complementary and Alternative Medicine BMI reduction involved 5 closed loops, the lower limit of the 95% CI of the discordance factor IF contained 0, and there was no significant discordance. e results of the consistency check are shown in Figures 5-7.

Results of Network Meta-Analysis.
e results of the total effective rate were as follows: the healing of acupoint catgut embedding was better than that of acupuncture, electroacupuncture, and exercise diet therapy (P < 0.05).

Sorting of Mesh Meta-Analysis Results.
ree different outcome indicators were ranked, and there were some differences in the ranking results. Lower average rank indicates better outcome indicators. Finally, it was revealed the intervention measures of acupoint catgut embedding combined with moxibustion showed a better effect in the treatment of simple obesity. e ranking of network metaanalysis results is shown in Table 4.

Publication Bias.
e funnel plot was drawn according to the total effective rate, and the scatter points were mostly located in the upper half, symmetrically distributed on both sides of the red indicator line, indicating small publication bias. However, there was a scatter at the bottom of the funnel plot, indicating a small sample effect, as shown in Figure 11.

Discussion
Simple obesity is defined as malnutrition without obvious causes. When the accumulation of body fat exceeds the consumption level of the body, the patient's weight exceeds the standard weight due to excessive body fat [43]. Nowadays, many factors are considered to be the etiology of obesity, such as neuroregulation, free radicals, and heredity [44,45]. In traditional Chinese medicine, it is believed that dysfunction of the spleen and stomach is the root cause of obesity. Increasing intake of sweet and greasy food and declining function of the spleen and stomach leads to accumulation of fat in the body. Obesity affects the quality of life of patients and damages their physical and mental health.
In clinical reports, acupoint catgut embedding is a safe and effective intervention for obesity. Adipocytes, adipose tissue, endocrine regulation, and inflammatory factors are the focus of study on the mechanism of action of acupoint catgut embedding in the treatment of simple obesity [46]. In the process of acupoint catgut embedding, needle insertion can cause tissue damage, fat cell death, or a small range of fat liquefaction and, to a certain extent, can reduce the number of cells in adipose tissue [47]. Under an optical microscope, less adipocytes, less Loop-specific lipid droplets in the cytoplasm, uniform cells, and more compact adipocytes were observed in obese mice [48]. Leptin (LP), as a product of adipocyte secretion, is a peptide hormone that acts on multiple tissues and organs through its receptor and has multiple effects on regulation of the body.
Yan Runhu [49] treated rats fed with high-fat diet for 12 weeks with catgut implantation at acupoints. e results showed that catgut implantation at acupoints could upregulate the expression of OB-Rb mRNA in the hypothalamus of obese rats and reduce the expression of SOCS-3 mRNA in hypothalamus cells and the content of SOCS-3 in peripheral blood serum, which suggested that catgut implantation at acupoints promoted signal transduction after LP and fasting insulin receptors, improved leptin resistance (LR) and insulin resistance (IR), and promoted LP and fasting insulin to exert biological effects. erefore, it can be used as an important mechanism of acupoint catgut embedding for weight loss. Deng Min [50] observed the effect of catgut implantation at acupoints on inflammatory factors in mice and found that catgut implantation at acupoints could inhibit the expression of interleukin-mRNA, tumor necrosis factor-α-mRNA, and monocyte chemoattractant protein-1 mRNA in adipose tissue and could reduce the occurrence and development of inflammatory reactions. erefore, it is further predicted that the possible mechanism of weight loss by catgut implantation at acupoints is to increase the expression of inflammatory factors in adipose tissue. e metaanalysis of acupoint catgut embedding and related therapies for obesity revealed that acupoint catgut embedding and other therapies showed a high healing rate in the treatment of simple obesity and could reduce the BMI of the patients [6]. Acupoint catgut embedding has become one of the effective measures for the treatment of obesity and has shown good clinical results with a variety of combined therapies, which are widely used [51].
To investigate the curative effect of catgut implantation at each acupoint and related therapies, a network metaanalysis was conducted. A total of 35 studies were included in this study, including 3040 patients. ere was a significant difference between the two groups before and after treatment. In network meta-analysis, the effect of various treatment methods was compared. Compared with traditional meta-analysis, it contains more original data. e statistical accuracy of different groups is not enough, but it has no impact on the final results of network meta-analysis [47]. is study ranked the improvement of treatment effect, body mass, and BMI of patients with simple obesity by comparing the treatments including acupoint catgut embedding, acupuncture, TCM, electroacupuncture, and exercise diet therapy alone, as well as the combination of acupoint catgut embedding with different therapies. e results of network meta-analysis showed that, in terms of total effective rate, the top three were acupoint catgut embedding + moxibustion, acupoint catgut embedding + TCM, and acupoint catgut embedding + cupping; in terms of reduced body mass of patients, the top three were acupoint catgut embedding + moxibustion, acupoint catgut embedding + exercise and diet therapy, and acupoint catgut embedding + cupping; and in terms of reduced BMI of patients, the top three were acupoint catgut   sequence method and do not blind the subjects and doctors, which may have an impact on the efficacy results. irdly, most of the observation indexes were body mass, effective rate, BMI, WC, HC, waist-hip ratio, and so on, lacking objective laboratory indexes. Finally, the short-term effect is good, but there are few follow-up records. e long-term effect needs to be further discussed. is systematic review aims to update and improve.

Conclusion
Acupoint catgut embedding and its combination with different therapies significantly increase the effective rate in treatment of simple obesity, resulting in improved body mass and BMI of the patients. e use of acupoint catgut embedding therapy is a better choice and provides a more reliable clinical reference. In clinical treatment, acupoint catgut embedding can be selected based on the conclusion of this study and considering syndrome differentiation. However, the conclusion is affected by the quality of the included studies, and this study needs more high-quality, large-sample RCT studies to verify.

Data Availability
e data used to support the findings of this study are available from the corresponding author upon request.

Conflicts of Interest
e authors declare that they have no conflicts of interest.  14 Evidence-Based Complementary and Alternative Medicine