Clinical observation on acupuncture for 80 patients with abdominal obesity in Germany: based on the theory of unblocking and regulating the Belt Vessel

To observe the efficacy of unblocking and regulating the Belt Vessel acupuncture method for patients with abdominal obesity in Germany and its influence on the body fat parameters and glycolipids metabolism. A total of 82 cases of abdominal obesity in Germany were selected. There were two dropout cases in the treatment process. All of the patients received acupuncture at Daimai (GB26), Daheng (SP15), Tianshu (ST25), Zhongwan (CV12), Shuidao (ST28), Waiguan (TE5), and Zulinqi (GB41). The patients received acupuncture therapy once every 2–3 d, 3 times a week. The treatment duration lasted 4 weeks. Before and after treatment, the body mass (BM), waist circumference (WC), abdominal circumference (AC), hip circumference (HC), total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and fasting blood glucose (GLU) were measured respectively, and the body mass index (BMI), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), and body fat rate (BFR) were calculated. After treatment, the total effective rate was 72.5%; the levels of BM, WC, AC, HC, BMI, WHR, WHtR, BFR, TC, LDL-C, and GLU declined significantly compared with those before treatment (P<0.01), while the TG and HDL-C slightly declined, but the differences were statistically insignificant (P>0.05). The unblocking and regulating the Belt Vessel acupuncture method can significantly reduce body fat parameters such as BM, AC, and BFR, and correct the disorders of glucose and lipid metabolism in patients with abdominal obesity in Germany.

increase of WC could significantly increase the risk of diabetes and cardiovascular diseases in Europe [1] , and the risk of all-cause death in patients with abdominal obesity is also significantly higher than that in patients without abdominal obesity [2] . Our previous clinical and basic research has confirmed that the acupuncture method of unblocking and regulating the Belt Vessel has a significant effect on improving abdominal obesity in China [3][4][5] . We applied this method to treat patients with abdominal obesity in Germany, and it is reported as follows.
1 Clinical Data

Diagnostic criteria
According to the diagnostic criteria of metabolic syndrome issued by the International Diabetes Federation in 2006 [6] , the abdominal obesity criteria for the European race are WC ≥94 cm for males and WC ≥80 cm for females.

Inclusion criteria
The above diagnostic criteria were met; aged 18-70 years old; signed informed consent and voluntarily participated in the study; if combined with dyslipidemia, hypertension, diabetes, coronary heart diseases, or other related risk factors, the diagnostic criteria for risk factors should be in accordance with the latest national diagnostic criteria.

Exclusion criteria
Secondary obesity and obesity syndrome caused by drugs or endocrine diseases; allergic constitution; severe organic disorders of the heart, brain, lung, liver, kidney, and blood system; pregnant or lactating women; those who had received other weight loss treatment in the recent three months.

General information
A total of 82 cases were selected between July 2020 and May 2021 in the Bad Koetzting Hospital of Beijing University of Chinese Medicine. Two cases fell off (discharged in advance due to family affairs and did not complete the corresponding course of treatment). Eighty cases completed the study, including 20 males (25%) and 60 females (75%). The ratio of male to female was 1:3. The minimum age was 35 years old, the maximum age was 70 years old, and the average age was (56.4±8.9) years old. This study was approved by the Ethics Committee of Bad Koetzting Hospital of Beijing University of Chinese Medicine.

Statistical methods
The SPSS version 20.0 software was used for statistical analysis. The measurement data were first tested for normality and homogeneity of variance. They were expressed as mean ± standard deviation ( x ±s) when meeting the normality and homogeneity of variance, and the paired t-test was used for comparisons before and after treatment. When the normality or homogeneity of variance was not met, the rank-sum test was used. P<0.05 was used as the standard to judge whether the difference was statistically significant.

Treatment Methods
Health education was carried out for the patients. During the treatment, the diet should be controlled properly. Meals should be eaten on time; regular work and rest should be carried out; snacks, excessive drinking, sweet food, and fried food should be avoided; and proper exercise should be carried out, such as a stroll and brisk walking.
Method: After routine disinfection of the skin, a filiform needle of 0.25 mm in diameter and 75 mm in length was perpendicularly punctured at Daimai (GB26) to a depth of 2 mm, and then the needle tip was turned inward and downward to the anterior superior iliac spine along the Belt Vessel. The needle insertion depth was 1-3 Cun to achieve needling sensation (Deqi), and the lifting-thrusting and twisting-reducing manipulations were applied. Other points were punctured perpendicularly with filiform needles of 0.25 mm in diameter and 40 mm in length, and the depth of insertion was 0.5-1.0 Cun. According to the differentiation of meridians, the deficiency should be reinforced, and the excess should be reduced. The needles were lifted, thrust, and twisted every 10 min and retained for 30 min each time. It was found that the sensitivity of German patients to acupuncture was stronger than that of Chinese patients, but the tolerance was poor. Therefore, acupuncture manipulations should be gentler, and the depth of acupuncture should be shallower for Germans. The treatment was performed once every 2-3 d, 3 times a week, for a total of 4 weeks.

Observation items 3.1.1 Simple body fat parameters
Measurements were taken before and after treatment. The patient took a standing position. Height and weight were measured. At the end of calm expiration, WC was measured by the midpoint between the inferior costal margin and the superior border of the iliac crest on the mid-axillary line. Abdominal circumference (AC) was measured around the umbilicus. Hip circumference (HC) was measured at the level of the anterior pubic symphysis, bilateral trochanter, and posterior gluteal muscle. Body mass index (BMI), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), and body fat rate (BFR) used to evaluate the fat content of adults were calculated. BMI  (HDL-C), low-density lipoprotein cholesterol (LDL-C), and fasting blood glucose (GLU) were measured before and after treatment. The patients with abnormal blood lipids and GLU were selected for comparisons before and after treatment. [7] Clinical recovery: After treatment, the WC of males <94 cm or females <80 cm, and BMI <25 kg/m 2 .

Clinical efficacy
Among the 80 patients with abdominal obesity, one case was cured, six cases were markedly effective, 51 cases were effective, and 22 cases were invalid. The total effective rate was 72.5%.

Comparison of changes in blood lipid and GLU before and after treatment
As shown in Table 2, after treatment, TC, TG, HDL-C, LDL-C, and GLU decreased by an average of (16.72±5.09) mg/dL, (44.82±15.99) mg/dL, (4.17±1.46) mg/dL, (9.58±2.71) mg/dL, and (17.00±3.52) mg/dL, respectively. There were significant differences in TC, LDL-C, and GLU before and after treatment (P<0.01), but there was no significant difference in TG or HDL-C before and after treatment (P>0.05). Note: BMI=Body mass index; WHR=Waist-to-hip ratio; WHtR=Waist-to-height ratio; BFR=Body fat rate; compared with the same parameter before treatment, 1) P<0.01. Note: Compared with the same parameter before treatment, 1) P<0.01.

Discussion
The World Health Organization pointed out in the 2014 summary report that obesity has more than doubled in the world since 1980 [8] . Overweight and obesity have become the fifth largest risk factor of global death, and the burden of obesity is particularly worrying for the elderly [9] . A Spanish multicenter study found that the prevalence of abdominal obesity in people over 65 years old (including 65 years old) was as high as 62% [10] . Abdominal obesity is closely related to cardiovascular disease [11][12] , diabetes [13] , stroke [14] , and cancer mortality [15] . Whether in developed or developing countries, the incidence of abdominal obesity is increasing yearly, and the further development of abdominal obesity into a chronic disease is the evolution of the current disease [16] . Therefore, early intervention in abdominal obesity may reduce the occurrence and development of many chronic diseases.
There is no such term as "obesity" in ancient books of traditional Chinese medicine. According to the relevant description in Huang Di Nei Jing (Yellow Emperor's Inner Classic), obesity can be divided into three types: "Zhi Ren", "Gao Ren", and "Rou Ren". Among them, "Gao Ren" is characterized by a plump abdomen, flabby muscle, and loose skin, similar to abdominal obesity in modern medicine [17] . The Belt Vessel starts from Zhangmen (LR13) in the quarter rib. It passes through Daimai (GB26), encircling the body like a belt. The Belt Vessel is the only transverse meridian in the human body, and it has the function of restricting the longitudinal meridians and coordinating the movement of Qi and blood. If the Belt Vessel is running abnormally, the longitudinal meridians will be out of control; the Qi movement will lose its balance; the clear Yang will not rise, while the turbid Yin will not fall; the clear and turbid will not be separated, but turn into phlegm turbidity and accumulate in the abdomen, leading to obesity [18] .
Some researchers think that the Belt Vessel is not just a line but 12 horizontal lines from the whole abdomen to the rib and down to Qijie (pathway of Qi), which is highly consistent with the occurrence of abdominal obesity [19] . Therefore, acupuncture treatment of abdominal obesity from the perspective of regulating the Belt Vessel can not only regulate the Belt Vessel and restore the restraining effect of the Belt Vessel on the longitudinal meridians but also conform to the local point selection and more targeted intervention in the adipose tissue of the abdomen. According to the theory of unblocking and regulating the Belt Vessel, Daimai (GB26), Daheng (SP15), Tianshu (ST25), Zhongwan (CV12), Shuidao (ST28), Waiguan (TE5), and Zulinqi (GB41) have significant effects on reducing the weight, WC, WHR, WHtR, and BFR of patients with abdominal obesity, and can also decrease the levels of blood glucose and lipids [20] .
Our previous study found that the Belt Vessel regulation method could effectively improve body fat parameters such as body weight, WC, and HC of domestic abdominal obesity patients and reduce visceral fat content [4] . Although the results of this study show that this acupuncture method is also effective in improving abdominal obesity in Germans, due to the limited conditions in foreign countries, there was a lack of comparison of the visceral fat content of patients in this study, and the treatment cycle was also short. If conditions permit, we will increase relevant research indicators and extend the treatment cycle to further explore the long-term effect of acupuncture on this disease.