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Concepts of body constitution, health and sub-health from traditional Chinese medicine perspective
Rose YP Chan, Wai Tong Chien
Rose YP Chan, Wai Tong Chien, School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, China
ORCID number: $[AuthorORCIDs]
Author contributions: Chan RYP contributed to literature search and review, preparation of the manuscript; Chien WT contributed to literature review, editing and finalizing the manuscript.
Correspondence to: Wai Tong Chien, Professor, School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, China. firstname.lastname@example.org
Telephone: +852-27665648 Fax: +852-23649663
Received: June 4, 2013 Revised: July 27, 2013 Accepted: August 17, 2013 Published online: December 12, 2013
This paper described and discussed the important literature and ideas about the concepts, types and measurement of body constitution, in terms of healthy, sub-healthy and disease status. In view of traditional Chinese medicine, ‘‘healthy” state is a status of relative balance of Yin and Yang to keep our bodily homeostasis. If there are significant physical and/or psychological stressors, such as loss of a beloved one and failure in study or work, the body can no longer keep its own bodily condition balanced and subsequently enter a state of ‘‘sub-health” (sub-optimal health). ‘‘unhealthy” body constitution such as ‘‘Dampness-heat”, ‘‘Cold-dampness” and ‘‘Heat- or Cold- dryness” with a subnormal body temperature and humidity and clinical manifestations such as insomnia, malaise and overweight will be presented. Immediate, appropriate strategies such as modification of life-style and seeking medical treatment can prevent evolution of an illness. Otherwise, the body will enter a disease status with a ‘‘pathological” body constitution of ‘‘Yin or Yang deficiency’’, ‘‘Blood-stasis” and/or ‘‘Phlegm-dampness”. To be complimentary with health promotion and disease prevention in Western medicine, understanding about an individual’s body constitution, together with its determinants (e.g., healthy eating and lifestyle behaviors), can contribute to a more proactive, holistic and individualized healthcare.
Core tip: This article discussed the concepts of body constitution in traditional Chinese medicine, which can reveal and advocate an individual’s bodily condition and functioning and thus contribute to a more proactive, holistic and individualized healthcare. We critically discussed the concepts, types and measurements of body constitution in terms of three main health statuses - healthy, sub-healthy and disease. With better categorized ‘‘healthy”, “sub-healthy” and ‘‘unhealthy’’ patterns of one’s body constitution, the levels of bodily resistance (strong or weak) and functioning of internal organs (adaptive or mal-adaptive), as well as the balance of “Yin and Yang’’, can be easily differentiated and maintained.
Citation: Chan RY, Chien WT. Concepts of body constitution, health and sub-health from traditional Chinese medicine perspective. World J Transl Med 2013; 2(3): 56-66
Chronic diseases such as cancer, arthritis, dementia and stroke impose wide varieties of medical and health problems and poor quality of life and even take away a lot of people’s lives every year. As a result, these diseases can cause huge burden to the health care costs across countries. In addition, it is also estimated that the aged population (65 years old or above) will increase from about 8% in 2010 to 16% in 2050. As such, the incidence and prevalence of chronic diseases, especially in the middle age and older people, will continue up-surging. Besides disease prevention, prophylactic intervention such as healthy eating and lifestyle and early seeking medical advices and treatments can be considered in health promotion and/or interfering the disease development during the pre-morbid stage.
‘‘Sub-health’’ is commonly used to describe the condition of pre-morbid or prodromal stage of health problems among health professionals in mainland China. The concept of ‘‘sub-health’’ was developed on the basis of the ‘‘third state of health’’ first introduced by Professor Buhemann in the Soviet Union, to describe there is a sub-optimal health status in-between the healthy and disease condition. People who have subjective complaints about early symptoms and discomfort may not receive a confirmed medical diagnosis by the physician (Western medicine) because of the negative or unclear results of medical or pathological investigations. According to a survey conducted in 2006 on 3624 people in China, more than 75% was at the state of sub-health. The researchers suggested that majority of these people might soon proceed to certain kinds of medical disease, if not treated or intervened. However, many people may feel unacceptable, unbelievable and helpless at the time of receiving a medical diagnosis of one life-threatening disease; and sometimes, they may feel regretful for not having taken care of themselves or their beloved one properly. It is therefore questionable whether we can intervene on the sub-healthy condition with prophylactic treatments before it is confirmed with a medical diagnosis.
Traditional Chinese medicine (TCM) advocates ‘‘treating an illness before it happens’’, that is to give intervention or treatment according to one’s body constitution whenever it shows changes in patterns and thus appears to be unhealthy. The term ‘‘body constitution’’ (BC) is commonly used in Chinese medicinal literature and culture to describe one’s current health status, reflecting his/her bodily condition and functioning. People are empowered to take care of themselves with lifestyle modifications and/or proper dietary practices, according to their BC prior to any illness occurrence, and thus crucial to ‘‘promote health, prevent disease and enhance longevity”. TCM practitioners give individualized treatment to each client according to his/her BC and treat disease ‘‘from its root” (i.e., the causes or rationale behind the presenting signs and symptoms). Therefore, knowing one’s own BC is one of the most important steps to promote his/her health condition, as well as his/her quality of life.
In recent 30 years, TCM practitioners and researchers have put much effort to develop a clear concept of BC. But till now vigorous debates and discussions are persisted on several important topics, including mainly the definition and types of BC, categorization of BC by using the common medical terms of TCM, and symptom differentiation in terms of different types of BC. In views of the complexity of the concept of and different beliefs and perspectives toward BC, this paper is to describe and discuss the important concepts and views of BC in terms of health, sub-health and disease conditions in order to increase our understanding and reveal the significance of BC to the knowledge of TCM, as well as our health and well-being.
CONCEPT OF BODY CONSTITUTION AND ITS MEASUREMENT
Starting from the ancient time, people have been very interested in knowing the commonalities and differences on characteristics and features of human beings, between individuals and/or among ethnic groups/flora. Interestingly, even though different perspectives or systems between the Western and Eastern parts of the world, their central themes or concepts of classification of biological features in humans or animals are very similar. In general, people are classified into groups based on their morphology, which is similar to elephant or deer, or on a whole picture of physiological and psychological conditions such as in terms of ‘‘four body fluids’’ introduced by Hippocrates, including sanguine, phlegmatic, bilious, and melancholic. This belief is compatible with the principles of TCM in understanding about the ‘‘types, shapes and states’’ of a human body in relation to BC stated in the Yellow Emperor’s Canon of Medicine. According to the ‘‘Yin-Yang’’ theory, different body appearances and personalities can be classified into ‘‘25 Types of People’’ in terms of their skin color, body shape, personality, and adaptation to natural environment and climate change.
Not until the Hon Dynasty, a famous TCM scholar Cheung Chung-king indicated that the body nature or condition was related to the disease occurrence, development, treatment and prognosis. He suggested that different kinds and severity of symptoms could co-exist in the course of the illness for different people even when they suffered from the same disease, or received the same medical diagnosis. This may be due to the differences on their individual body conditions, which can be categorized people into different types of body characteristics such as strong, weak, ulcer, and bleeding types, regarding one’s risk or tendency of disease development. Cheung’s suggestions had nourished the concept of BC and researchers started to adopt TCM terms in the classification of BC in the late 19th century. A few TCM experts in China, especially Professor Kuang DY and Professor Wang Q, shared about their views and initiated in establishing the theoretical framework and concepts of BC.
Conceptually, BC represents the nature of the person’s morphosis, physical and psychological components at one point of time, or sometimes a short period. Although Kuang argued that one’s psychological status should be classified in terms of temperament, it is well known to be affected by both congenital and acquired factors, together with relative group tendency (in relation to their environmental and cultural situations) and absolutely personalized bodily condition. Each person should possess a few characteristics similar to their ancestors such as skin and hair colors, bodily appearance and features and stature. Similarities and commonalities of basic bodily health and functioning may co-exist in a racial or an ethnic group, because they are likely to share common characteristics and backgrounds in relation to their living environment, race, eating behaviors and life habits, interest, and basic genetic manifestations. For instance, a group of children or elderly people who are at the same developmental stage may possess similar bodily features and physiological characteristics earmarked by that particular human developmental stage. Interestingly, the BC of the closest family members such as parents, siblings and twins can be unique, while some diseases such as Hepatitis B carriage gene can be inherited from parents. In addition, body frame of the Western people are often bigger than that of the Eastern people because of their differences on genetic manifestation. Due to different combinations of personal, environmental, social, cultural and geographical factors, the BC of people can be absolutely different between each other. Parents’ health, especially those mothers during pregnancy and even genetic changes or mutations, can impose much varied levels of impacts to the bodily condition of the next generation. For instance, congenital heart disease may be developed when fetus is growing in his/her mother’s uterus, and the HIV infection can be transmitted during birth.
Despite one’s BC being influenced by various external (e.g., environment and climate) or internal (e.g., hormonal or sudden changes in biological conditions) factors, it seems relatively stable due to the governance of family inheritance or genetics, race and sex, imposing lifelong effects to an individual’s bodily condition. Throughout one’s developmental life stages, BC changes progressively within and between each life mileage and, however, critically in a few essential life stages such as from children to adolescence. But prolonged or significant internal and external factors may induce continuous changes, or capricious shifts in different lifestyle patterns or behaviors such as work, eating behaviors and living environment. However, these effects to the BC may become settled, or constant, once the person can adapt well to the influencing factors, resulting from an effective buffering mechanism (‘‘strong’’ in bodily condition) inside the human body[22,23]. But if the stress or its ill effects are prolonged, negative (maladaptive) and dysfunctional patterns of BC will appear.
Kuang indicated that BC would initiate pathological changes within body during the transitional periods of pre-diagnosis (prodromal stage) and convalescence. Therefore, it is believed that BC may contribute to the level of susceptibility and clinical outcomes of a disease, presenting in various forms, characteristics (like signs and symptoms), or patterns of resistance and reactions towards the existing internal and external stimuli. Therefore, Kuang also suggested that physical and psychosocial development and environmental changes of an individual can induce progressive changes to one’s BC; and its obvious changes often occur during the life development milestones such as pregnancy, middle age and menopause.
In addition, shifts of types and features of BC will also be caused by both internal and external factors, including parents’ health and inheritance, environmental stressful situations and emotional frustrations, exercise and eating habit, bodily disease and treatment. Similarly, it is also believed that ‘‘unhealthy’’ BC can be adjusted by medications and diet. Modifications of parents’ or mother’s BC could indirectly improve, or jeopardize, the health status of their baby over the period of fertilization and/or pregnancy.
In order to understand one’s own BC, on-going assessment by using the four classical diagnostic skills of TCM, including inspection (patient’s facial colour, tongue sign and external appearance), listening (patient’s voice and coughing sound) and smelling (patient’s body odour), inquiry (patient’s complaint) and palpation (patient’s body part and pulse) and questioning are crucial.
Different measurement tools of BC can also be considered in TCM diagnosis and research. The 60 items Constitution in Chinese Medicine Questionnaire (CCMQ) is a widely used assessment tool in China developed by Zhu et al in 2006 to measure nine types of BC, including Gentleness, Qi-deficiency, Yang-deficiency, Yin-deficiency, Phlegm-wetness, Wet-heat, Blood-stasis, Qi-depression and Special diathesis. The strength of the scale is the vigorous face and content validity done by the Chinese Medicinal experts. However, a few limitations are noted. First, only concurrent validity has been demonstrated with SF 36 and body mass index, and thus the sensitivity and specificity of the instrument is in doubt. In principle, healthy BC should not be identified in patients with disease. Interestingly, ‘‘Gentleness’’ (healthy) type of BC was identified in ill persons, using this CCMQ, such as 37.4% of 147 subjects with liver cancer and 43.6% of 101 subjects with hypertension. Another concern is the use of retrospective data that examined on the signs of illness within one year is considered unreliable due to the result bias and difficulty in reporting those repeatedly occurring items. Wang et al criticized that the nine subscale (i.e., nine types of BC) of the CCMQ was confusing, non-specific in categorizing BC types, and indicating inconsistent of results by using both the Chinese Medicinal terms in pattern differentiation and the allergic reaction in Western Medicine (especially for the ‘‘Special diathesis” subscale). The specificity of the instruments are questionable in assessment of BC.
Ho et al in 1996 developed a 96-item Chinese Construction Questionnaire (CCQ) by clustering analysis of > 5000 sets of data from people in different provinces of China to identify six types of BC, including ‘‘Strong’’, ‘‘Weak’’, ‘‘Trend-Cold’’, ‘‘Trend-Heat’’, ‘‘Trend-Dampness’’, and ‘‘Blood-stasis’’. This assessment scale is flexible in detecting types of BC; clustering analysis can be used in order to identify additional types of BC based on the six basic types mentioned above. Researchers identified eight types of BC in 809 hepatitis B patients, and 16 types in 879 obesity people by using the CCQ. As the questionnaire is too lengthy and with limited evidence on reliability and validity, it has not yet been widely used.
In Taiwan, Su in 2008 developed a self-rating 22-item BCQ+: A Body Constitution Questionnaire to assess Yang-Xu (i.e., the energy levels of different bodily functions in terms of five internal viscera). The questionnaire is easily administered and indicated satisfactory psychometric properties such as content validity and internal consistency. Nevertheless, it only focuses on a single dimension of bodily condition (Yang-Xu) and thus shows incomplete picture of BC. Similarly, several scales measuring single type of BC such as the Yin-deficiency Questionnaire, Yin Scores and Yang Scores, and Cold-Heat Pattern Questionnaire, Phlegm Pattern Questionnaire, and Kidney deficiency Syndrome questionnaire (KDSQ) have been found for TCM diagnosis. There are also a few measurement tools of health condition using the concept of BC, such as the Health Scale of Traditional Chinese Medicine assessing health perception and Chinese Quality of Life Instrument assessing the health-related quality of life.
In conclusion, BC not only can describe and represent the current bodily condition of an individual, which is relatively stable over time, but also can reveal progressive changes and responses toward the internal and external stimulations in a person’s body. A healthy person with strong and functional internal organs is able to better adapt and remain healthy if the overall stimulations and their bodily responses are below one’s threshold of bodily resistance or satisfactorily coped with homeostasis mechanisms of the body. This is also compatible to the concept of ‘‘health and illness continuum’’ in Western medicine, in which health of every person condition is not constant, for instance, people may feel mild discomfort during daytime but then they feel better again spontaneously or after taking rest and self-regulatory actions such as taking a snap and drinking cups of water. However, for a vulnerable person with sub-normal function of the internal organ(s), or ‘‘sub-health’’, progressive pathological changes will occur and thus the person’s health condition may shift from a normal or ‘‘healthy’’ to an ‘‘abnormal’’ BC.
Common types of BC
In general, two major types of BC, including normal and abnormal, can be categorized and considered to be more simplified and easily understood in describing one’s bodily condition and functioning. While the term ‘‘normal’’ implied a healthy, positive and good, a ‘‘normal or healthy’’ BC should be pointed to an absolute healthy condition without any signs of disease and on the other hand, with strong and pleasant appearance and good functioning in all main body organs and systems such as nervous, cardiovascular and respiratory system, as well as being able to indicate ‘‘normal’’ results in various physical and psychological investigations. A normal BC should also present with good hardiness and quality of life and having adequate ability of coping with stress, and high adaptability to external socio-economical and natural environments. On the other hand, an ‘‘abnormal’’ BC implied unhealthy, negative or poor bodily condition. Wang adopted the term ‘‘biased’’ or ‘‘deviated’’ to describe such an abnormal condition, describing it as ‘‘sub-health’’ in association with specific type(s) of disease(s) or ill condition. However, most recent classifications of BC focused on the pathological changes of the bodily condition, thus increasing the use of more complex pattern differentiations to classify different types of BC.
In modern China, researchers based on the perspective of TCM practitioners to develop more than 60 taxonomies of BC. As suggested by Kuang, while many practitioners may believe that BC were mainly abnormal relating to pathological changes, it is noteworthy that some have recognized a few types of BC to be ‘‘healthy’’ or ‘‘normal’’. The classifications of BC much varied, from two to 16 types. Recently, Kung has summarized 19 major classifications of BC (see Table 1) developed between 1978 and 2002.
Table 1 Classifications of body constitution (1978–2002).
Authors andnumber of types
Types of body constitution
Soet al(1996); 3 types
Balance type; Spleen-Lung type; and Spleen-Kidney type
Liet al[51(1996); 3 types
Yang exuberance type; Yin exuberance type; and Yin and Yang harmony type
Huet al(1987); 4 types
Harmony type; Functional exuberance type; Functional deficiency type; and Functional exuberance and deficiency type
Zhuet al(1989); 5 types
Normal type; Phlegm-dampness type; Qi-deficiency type; Internal-heat type; and Qi-Yin deficiency type
Wanet al(1998); 5 types
Yin and Yang balance type; Heat-stagnation type; Spleen-Stomach Qi-deficiency type; Spleen-Stomach Yin-deficiency type; and Spleen-Stomach Qi-Yin-deficiency type
Kaunget al(1978); 6 types
Normal type; Heat-dryness type; Blood-stasis type; Phlegm-wetness type; Yang-deficiency type; and Fatigue-pale type
Hoet al(1986); 6 types
Normal type; Yin-deficiency type; Yang-deficiency type; Yin & Yang-deficiency type; Phlegm-wetness type; and Blood-stasis type
Hoet al(1996); 6 types
Strong type; Weak type; Trend-cold type; Trend-heat type; Trend-dampness type; and Blood-stasis type
Panget al(1985); 7 types
Normal type; Excess-heat type; Qi-stagnation blood-stasis type; Phlegm-dampness type; Deficiency-cold type; Qi-blood deficiency type; and Yin-deficiency type
Qinet al(1984); 7 types
Norma type; Yin-deficiency type; Yang-deficiency type; Phlegm-dampness type; Qi-deficiency type; Heat-dampness type; and Blood-stasis type
Wanget al(1995); 7 types
Normal type; Spleen-insufficient type; Kidney-insufficient type; Lung-insufficient type; Liver-insufficient type; Heart-insufficient type; and Fetus-heat type
Chenet al(1988); 7 types
Normal type; Yin-deficiency type; Yang-deficiency type; Kidney-deficiency type; Qi-Blood-deficiency type; Phlegm-dampness type; and Blood-stasis type
Chenet al(1998); 7 types
Normal type; Yin-deficiency type; Yang-deficiency type; Phlegm-dampness type; Qi-blood-deficiency type; Fatigue type; and Yang- exuberance type
Wanget al(2002); 7 types
Gentleness type; Yin-deficiency type; Yang-deficiency type; Qi-deficiency type; Blood-stasis type; Phlegm-dampness; and Heat-dampness type
Wanget al(1984); 9 types
Yang type; Yin type; Yin-deficiency type; Yang-deficiency type; Heart-deficiency type; Liver-excess type; Spleen-deficiency type; Lung-deficiency type; and Kidney-deficiency type
Muet al(1983); 9 types
Qi-deficiency type; Blood-deficiency type; Phlegm-wetness type; Blood-stasis type; Yang-deficiency type; Yin-deficiency type; Yin-exuberance type; Yang-exuberance type; and Qi-stagnation type
All of them were developed on the basis of the theories of TCM and clinical symptoms of diseases. One major commonality among these classifications is that they have adopted ‘‘patterns’’ (of features or signs) in the concept of TCM to explain the bodily condition. For instance, 10 of them considered the level of ‘‘fluid’’, ‘‘Qi’’ and ‘‘Blood’’, 9 adopted the theory of ‘‘Yin and Yang’’, 10 adopted ‘‘Phlegm’’, and 3 included ‘‘Hot” and ‘‘Cold’’. In addition, the other concepts included in the classifications like ‘‘Strong’’ and ‘‘Weak’’ (in 2 classifications), visceral functions (6 of them), and ‘‘normal’’ types of BC (15 of them). In recent years (2006-2013), most TCM researchers based on Wang’s nine types of BC (Gentleness, Qi-deficiency, Yang-deficiency, Yin-deficiency, Phlegm-dampness, Heat-dampness, Blood-stasis, Qi-depression, and Special diathesis) to look into different kinds of illnesses or diseases, in particular dementia, ischemic stroke, osteoporosis and renal disease. Based on Ho’s six basic types of BC, a few TCM researchers also identified eight types of BC (Normal, Qi-depression, Qi- deficiency, Stagnation, Yin-deficiency, Deficient-cold, Internal-heat , and Anxious) to assess health condition of people with hypertension and coronary heart disease.
Another major classification of BC is based on the functioning of internal organs, commonly used in bronchitis asthma and post-infection condition of children. ‘‘Yin and Yang’’ types of BC have been used for assessing the BC concerning insomnia; and Five Elements (‘‘Metal’’, ‘‘Wood’’, ‘‘Fire’’, ‘‘Earth’’, and ‘‘Water’’) and ‘‘Cold’’and ‘‘Heat’’ types are commonly used in examination and diagnosis of with metabolic disorder and naso-pharyngeal carcinoma, respectively.
Though there are different types of classification of BC, we can conclude that all types of BC can be categorized according to ‘‘patterns’’, or contrasting (like opposite ends) features or states described in TCM, such as ‘‘Yin and Yang’’ (deficient or excess), ‘‘Blood’’ and ‘‘Qi’’ (stasis, deficiency or stagnation), functional excess or deficiency (Spleen, Heart, Lung, Kidney and Liver), and ‘‘Phlegm and Wetness”, except a few ‘‘normal’’ BC. There are 15 out of 19 commonly used classifications included the ‘‘healthy’’ BC as one of the major types; and the rest classifies BC as various bodily conditions at risk of some kinds of diseases with manifestation of certain pathological changes. In addition to the four classical assessment skills in TCM (inspection, auscultation and olfaction, inquiry, and pulse taking and palpation) used, it is recommended that for the purpose of primary prevention and routine screening, user-friendly, efficient and appropriate approaches of BC assessment for the general public should be developed. In order to enhance self-evaluation of one’s own BC, self-report valid questionnaires should be designed, whereas a few have been developed and obtained preliminary evidence on their reliability and validity (e.g., Body Constitution Questionnaire to assess ‘‘Stasis’’ type of BC).
World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity”; and reproductive health also addresses the reproductive processes, functions and system at all stages of life. This definition is compatible to the concept of TCM in which ‘‘Yin and Yang’’ harmony (balance) makes one ‘‘healthy’’. ‘‘Yin’’ and ‘‘Yang’’ works together to make body condition or functions in balanced state or status quo (homeostasis), in order to maintain a normal or healthy condition and functioning of the internal organs, emotional state (e.g., free of discomfort), resistance and adaptation to those internal and external stimulations. Figure 1 presents and illustrates the state of the balance between the four main elements of bodily conditions (i.e., ‘‘Cool’’, ‘‘Wet’’, ‘‘Dry’’ and ‘‘Heat’’) in relation to temperature and humidity.
Figure 1 Diagram showing the types of body constitution in relation to health, sub-health and disease status.
Relatively constant body temperature is crucial to maintain homeostasis. Because stable body temperature will allow normal enzyme function and indirectly affect the level of body fluid. The level of humidity and temperature in the human body varies in terms of both the internal and external stimulations, resulting in different combinations of physical, chemical and biological reactions inside the body. ‘‘Yang’’ is the function of the internal organs accounting for producing heat, while ‘‘Yin’’ is the flow of substances or fluids throughout the body or its organs such as water, blood, cells, and endocrine secretions in order to support their functioning (‘‘Yang’’). Therefore, both ‘‘Yin” and ‘‘Yang’’ contribute to maintain stable temperature within the human body. ‘‘Yin-Yang’’ balance refers to the harmony in nature, internal, mental, and physical conditions or statuses, and thus the whole body is in a well-functioned and optimal state to tackle any stimulation against the thresholds of body organs, tissues and other functional units. Such type of ‘‘healthy’’ BC should include the ‘‘Heat, Cool, Dry and Wet (dampness)’’ dimensions in a somewhat balanced state. For example, when the external temperature is high, a few cups of water can replenish the evaporated body fluid, and allay one’s thirsty, in line with the concept of ‘‘health and illness continuum’’. Human body can adapt to temperature changes by using a natural physiological response such as sweating and shivering as “Heat adaptation’’ by a series of reactions in cardiovascular, sudomotor and neuro-endocrine of the body. As long as the ‘‘Yin’’ and ‘‘Yang’’ is in a balanced state, the interrelated bodily mechanisms can work well together to maintain the body condition and functions as ‘‘healthy’’ or normal; otherwise, when beyond the thresholds, the body will at risk of ‘‘sub-health’’, or crossing the border from a ‘‘normal’’ to an ‘‘abnormal’’ BC.
Sub-health, or called the ‘‘third state’’, is an individual’s health condition between healthy and being ill as a result of mal-adaptive or abnormal bodily reactions toward internal and/or external stimuli such as infectious diseases, environmental pollution and stressful life situations. This concept is to describe those who are presenting with a few observable subjective complaints such as low and depressed mood, irritability, anxiety, fatigue and muscle pain, but their illness condition cannot be confirmed or diagnosed in Western medicine, due to negative results in medical and clinical investigations.
However, the human body at this pre-morbid stage (sub-health) is definitely at risk of some types of diseases due to the person’s inability of keeping his bodily condition in homoeothermic or homeostatic state[85,86]. Biochemical and psychological regulatory mechanisms inside our body that can sustain our life and maintain harmony could be lost when the person is unable to maintain a stable core temperature (around 97.6-99.6 °C or 36.5-37.5 °C and bodily functions such as normal cardiovascular and excretory functions. For instance, when body temperature exceeds the threshold in case of the internal buffering system cannot working properly, the core temperature will be raised; and such elevated core temperature can have heat-associated symptoms such as muscle weakness, lightheadedness, dizziness, sleepiness, fatigue, and confusion[87,88]. Without proper adjustment of body temperature by homeostatic mechanisms such as by sweating and vasodilatation, the person will feel discomfort (when skin temperature beyond the normal range of 36.5-37.5 °C), and even present increasing levels of disabilities and dysfunctions of various body parts when persistent changes in external or internal temperature occur. According to the theories of TCM, ‘‘Cold’’ (Cool) and ‘‘Heat’’ (Hot) nature of BC in response to changes in body temperature would eventually induce pathological changes inside the human body.
Therefore, BC can shift from healthy to unhealthy patterns according to the patterns of symptom differentiation, including ‘‘Cold’’vs‘‘Heat’’, ‘‘Dampness’’vs‘‘Dryness’’, ‘‘Heat-dampness’’vs‘‘Cold-dampness’’ at different levels (low vs high) of temperature and/or humidity, which are the important parts of natural environment that the person is situated. Dry and hot environment can induce biochemical reactions inside the body to become ‘‘Heat’’ and ‘‘Dryness’’ patterns of BC; but if the body can adapt to this environment and then cool down the bodily functions, the person will present with ‘‘Cool’’and ‘‘Wet’’ patterns of BC. Before showing full adaptation to any of these stimuli, respective types and levels of clinical manifestations from mild discomfort to heavy headache and fainting may co-exist according to the pathological changes in the human body (i.e., so called BC in TCM). When a person presents mild discomfort or vivid changes in BC, it is not usually, or sometimes difficult, for a Western medical practitioner to prescribe treatment for the person without any medical diagnosis. However from the TCM perspective, inadequate rest, abnormally high or low external temperature and humidity, and/or extreme internal, emotional fluctuations can cause harmful effects to the body if not early intervened. It is because these can disrupt the balance of ‘‘Yin and Yang’’ and change the individual’s BC, thus imposing him/her a higher risk of illness occurrence.
In contrast to WHO’s definition, people are generally considered healthy when they are in absence of a medical diagnosis, or an obvious disease condition. In a recent study of 4832 Chinese people in Hong Kong, 83% perceived ‘‘satisfactory health status’’ irrespective of 27% having strong risk factors of chronic diseases such as obese, hypertension, hyper-cholesterolaemia and diabetes. Two studies of 400 and > 2000 so called ‘‘healthy’’ people (without clinical significant signs and symptoms) found that only 38.75% and 35% of them were classified with ‘‘healthy’’ BC, respectively; and the remaining majority were categorized having one of the ‘‘abnormal’’ types of BC, including ‘‘Fluid insufficiency’’, ‘‘Internal-heat’’ and ‘‘Heat-dumpness’’. ‘‘Heat-dampness’’ might also occur when their body temperature was high with fluid overload, resulting in hot feeling, obesity, very tiredness, bitty taste in mouth, and massive yellowish vaginal discharge . In longer term, such type of BC tends to develop obesity, and at risk of various chronic diseases, such as diabetes mellitus and coronary heart disease. With increasing research on BC, the concept of ‘‘sub-health’’ seems to be emerging and showing similarities to the pre-clinical or pre-morbid stage of diseases in Western medicine, but receiving much attention by TCM practitioners. Sub-health condition should be assessed and thus the person would be provided with preventive measures for disease occurrence and related suffering in future.
Further to the changes in BC discussed above for ‘‘sub-healthy’’ state, more pathological changes in BC would develop into ‘‘Yang’’ Deficiency, presenting with subnormal temperature and/or overload of body fluid, and subsequently proceeding to disturbance of endocrine secretions such as hormones in the hypothalamic pituitary adrenal and/or thyroid axis. Inability of standing with biological and psychological stressors would result in disease occurrence. On the other hand, ‘‘Yin-deficiency’’ is due to ‘‘Heat’’ and ‘‘Dryness’’, as well as inability of replenishing body fluid after an excess loss. The core temperature would then be increased and eventually resulted in cell and tissue damage, which is found compatible to the theory of tissue and cell inflammation and damage as the result of hyperthermia in Western medicine. In addition, ‘‘Blood stasis’’ due to unsatisfactory systematic circulation can occur if body temperature and humidity are low, presenting with feeling of numbness over the body, poor circulation, cool extremities, and purple lips, while ‘‘Phlegm-dampness’’ can be due to low temperature with high humidity in which people will present with cold feeling, edema, abnormal tiredness, and poor digestive function. These types of ‘‘unhealthy’’ BC reveal the overall concept of ‘‘Yin and ‘‘Yang’’ imbalance, which absolutely contributes to the sickness or disease occurrence.
Recent studies also reported that cancer patients with ‘‘Yin-deficiency’’ BC, which might present with higher heart rate and inability of regulation of body temperature, would increase morbidity and mortality over a few months of follow-up. ‘‘Yin-deficiency’’ type of BC with inadequate body fluid and high body temperature was evidenced to be one of the risk factors of dementia and hypertension. ‘‘Yang-deficiency’’ BC with low temperature and high fluid level, at risk to have osteoporosis after menopause and cancer.
BODY CONSTITUTION AND DISEASE PREVENTION
It is important to understand the concept of BC and to consider this to be applied to the prevention and treatment of chronic illnesses, whereas medical treatment in Western medicine may not be able to early detect, improve, maintain, or cure these illnesses. When the global population continues aging, the incidences and prevalence of chronic diseases will certainly increase. Prevention and early intervention strategies in these illnesses from the perspectives of TCM (and BC) should be carefully considered, particularly for those presenting with only pre-clinical or pre-morbid features and, at the same time, non-significant or negative results in clinical examinations. As emphasized by TCM, ‘‘Prevention is always better than cure’’.
Despite different views of BC found in recent research, BC can reflect the current body condition and reveal the functions of internal organs by direct observation of their signs or subjective complaints with four classical examination skills of TCM. Based on the principles of TCM, once these signs of illness appeared, appropriate early treatments or interventions would be needed for improving the individual’s BC. Yet, the abnormal BC would be modified and improved (converted or changed to a ‘‘healthy’’ BC) with herbal medication[7,8,19], as well as diet, nutrition and lifestyle behaviors[21,104]. Researchers conducted a dietary intervention study to improve an abnormal (‘‘Yin-deficiency’’) BC in 48 people with hypertension. Their results indicated the changes in dietary practice among the hypertensive subjects could modify their abnormal BC to become a ‘‘healthy’’ BC and at the same time, improved their pathological condition such as a decrease in hypertension and its related drug use.
During ‘‘sub-healthy’’ status, lifestyle and diet modifications may help the body refrain from deterioration of health condition or disease occurrence. Eating well with good bowel habit, sleeping well and doing exercise regularly are considered a few key elements to maintain body resistance against disease, from the TCM perspective. In Western culture, healthy eating is based on the concept of the ‘‘food pyramid” such as balanced diet or less fat and oils and more fruit and vegetables. In Chinese culture under the influence of TCM, foods with different combinations of ‘‘Cold’’ and ‘‘Hot’’ properties are thought to maintain harmony and a balance of ‘‘Yin and Yang’’ in our body. Food intake according to an individual’s BC may be the best way to enhance good health and longevity and prevention of diseases.
All along, the medical terms used for pattern differentiation in TCM have been adopted to set up the categories of ‘‘abnormal’’ or ‘‘pathological’’ BC. As there are more than 60 categories of patterns and many known classifications of BC, many of these patterns for differentiations are not consistent, still developing and modifying with TCM research over the last decade. However, it is useful to develop and use a simple, clear and user-friendly classification of BC with strong evidence-based patterns, in order to let the TCM and healthcare professionals and the public better understand and use of the concept of BC in detecting ‘‘sub-health” and ill health or disease.
This article critically discussed the BC, ‘‘sub-health’’, health, and disease conditions of an individual. Recent evidence in TCM supports that an individual’s body condition can be influenced by multiple internal and external factors, mainly including genetic, biochemical, ethnic, family, environmental, psychological and behavioral domains. With better categorized ‘‘healthy’’ and ‘‘unhealthy’’ BC patterns, a strong and weak bodily resistance, an adaptive and mal-adaptive functioning of internal organs, and thus a balance of ‘‘Yin’’ and ‘‘Yang’’ in the human body, can be easily identified and differentiated. Healthy people can easily adjust their body condition below the functional thresholds to prevent illness and stress reactions, and thus be more able to adapt to the changes in their internal and external environments, particularly temperature and humidity. Otherwise, less healthy people will shift from a healthy to a ‘‘sub-healthy’’ condition and then proceed to disease status if not appropriately early intervened. To be complimentary with health promotion and disease prevention in Western medicine, understanding about one’s BC in TCM, together with its important determinants (e.g., healthy eating and lifestyle behaviors), can contribute to a more proactive, holistic and individualized care in the community.
Bayliss M, Rendas-Baum R, White MK, Maruish M, Bjorner J, Tunis SL. Health-related quality of life (HRQL) for individuals with self-reported chronic physical and/or mental health conditions: panel survey of an adult sample in the United States.Health Qual Life Outcomes. 2012;10:154.
Bush H. Tackling the high cost of chronic disease.Hosp Health Netw. 2012;86:34-36, 38, 40.
Hu XM, Bai LX, Zhao J, Li XS, Wang LY, Guo XY, Liang Y, Lu ZX. Progress of sub-health research.Zhongguo jiankang jiaoyu. 2007;23:144-146.
Xie YM, Liu BY, Piao HY. Exploration on the common characters of sub-healthy people based on clinical epidemiology.Zhongguo Zhongxiyi Jiehe Zazhi. 2006;26:612-616.
Zhang ZL. Research of preventive treatment of disease of TCM.Zhongguo Zhongyiyao Xiandai Yuancheng Jiaoyu. 2013;11:84-85.
Sun LJ. Study and Interpret of Body Constitution in Chinese Medicine. Beijing: Zhongguo Zhongyiyao Chubanshe 2008; 3-5.
Wang Q. Individualized medicine, health medicine, and constitutional theory in Chinese medicine.Front Med. 2012;6:1-7.
Tong YY, Mei XY. A discussion on concept of “looking for basic cuases in treating diseases”.Nanjing zhongyiyao Daxue Xuebao. 2002;18:204-206.
Song WM. Further exploration on the problem related to classification of body constitution in Chinese medicine.Shandong Zhongyiyao Daxue Xuebao. 2008;32:291-292.
Diaoyuan K, Yongxia S. A brief history of human constitutionology.J Tradit Chin Med. 2006;26:230-238.
Wang J, Li Y, Ni C, Zhang H, Li L, Wang Q. Cognition research and constitutional classification in Chinese medicine.Am J Chin Med. 2011;39:651-660.
Wang NN, Zhang JM. Constitution thoughts in treatise on febrile disease.Henan Zhongyi. 2007;27:9.
Han YM, Zhang LT. Characteristic of constitution theory in traditional Chinese medicine.Zhongyi Linchuang Kangfu. 2005;9:130-131.
Kuang DY. Discuss again on human-constitution, temperament and their typology.Zhonghua Zhongyiyao Xuekan. 2011;29:1478-1481.
Cen H, Wang Q. The investigations and analysis on distributions of constitution in population of different age.Zhongyi Linchuang Kangfu. 2007;25:1126-1127.
Levy HL, Guldberg P, Güttler F, Hanley WB, Matalon R, Rouse BM, Trefz F, Azen C, Allred EN, de la Cruz F. Congenital heart disease in maternal phenylketonuria: report from the Maternal PKU Collaborative Study.Pediatr Res. 2001;49:636-642.
Kourtis AP, Bulterys M. Mother-to-child transmission of HIV: pathogenesis, mechanisms and pathways.Clin Perinatol. 2010;37:721-737, vii.
Kuang DY. Human Constitutionology Principles of Individualized Diagnosis and Treatment in Traditional Chinese Medicine. Taiwan: Wen Kuang Publishing Company 2008; 77-101.
Wu HY, Hsu CH, Deng SM, Hu WL, Hung YC. To analyze the factors of constitutions of shift nurses.Zhongguo Yiyue Zazhi. 2012;23:73-82.
Chen AL, Zhao LC, Ruan JY, Lau CY, Wang WY, Lau YY, Lui KT, Yu Y, Wang C. Epidemiological investigation of life style on body constitution.Shanxi Zhongyi. 2009;25:42-43.
Liu YM, Wang GX. Promoting the adaptability of the society is the aim of the physical education in health.Qufu Shifan Daxue Xuedao. 2004;30:98-101.
Xutian S, Zhang J, Louise W. New exploration and understanding of traditional Chinese medicine.Am J Chin Med. 2009;37:411-426.
Kuang DY. Discussion on the difference between zheng and constitutional types.Zhongguo Zhongyi Jichu Yixue Zazhi. 2002;8:81-85.
Lew-Ting CY, Hurwicz ML, Berkanovic E. Personal constitution and health status among Chinese elderly in Taipei and Los Angeles.Soc Sci Med. 1998;47:821-830.
Keung H, Keung KK. Discussion the impact of disease towards body constitution.Xin Zhongyi. 2006;38:7-9.
Wang Q, Ni Cheng. The theory of prescription in accordance with constitution.Tianjin Zhongyiyao. 2009;26:1.
Kuang DY. Outline of the constitutional food adjusting theory.Zhejiang Zhongyiyao Daxue Xuebao. 2006;30:217-219.
Wang Q. Discussion of 3 key problems of the research in TCM body constitution (lower part).Zhongyi Zazhi. 2006;47:329-332.
Wang J, Yang XZ, Zhu QW, Dong XY, Li HY, Guo Z, Niu X. Chinese medicine four diagnoses auxiliary apparatus in health evaluation and constitution identification.Shjie Kexue Jishu–Zhongyiyao Xiandaihua. 2010;13:70-73.
Zhu YB, Wang Q, Xue HS, Orikasa Q. Preliminary assessment on performance of Constitution in Chinese Medicine Questionnaire.Zhongguo Linchuang Kangfu. 2006;10:15-17.
Zhu YB, Wang Q, Hideki O. Evaluation on reliability and validity of the constitution in Chinese medicine questionnaire (CCMQ).Zhongguo Xingwei Yixue Kexue. 2007;16:651-654.
Yu HJ, Peng T, Xiao KY, Zhang YQ, Zhai ZF, Zhai XF, Li B. Epidemiological study on traditional Chinese medicine constitution types in patients with primary liver cancer in Guangxi Province, China.Anhui Zhongyi Xueyuan Xuebao. 2012;31:7-9.
Wu JH, Yang TL, Liu GH, Chern MS, Tsay PK, Shen JJ, Lee KC, You JS. Study on constitutional discrimination of 101 cases of primary hypertension.Zhongyue Yixue Zazhi. 2007;18:113-119.
Wang K. Deliberation body constitution research method in Chinese medicine.Huanqiu Zhongyiyao. 2010;3:295-297.
Ho YM, Wang L, Shek FT, Chor KM, Cheung TF, Chui W. Cluttering research of body constitution.Zhongguo Zhongyi Jichu Yixue Zazhi. 1996;2:7-9.
Chan LY, Chan KK, Chui LY, Cheung TY, Liu ML. Investigation on the body constitution type of patients with hepatitis B infection in Chinese medicine.Jilin Zhongyiyao. 2011;31:44-45.
Kow PY, Chu KM, Chiu TT, Ho YM. Study of the body constitution of obesity people in Chinese medicine.Guoyi Luntan. 2001;16:21-24.
Lin JS, Chen LL, Lin JD, Chang CH, Huang CH, Mayer PK, Su YC. BCQ-: A Body Constitution Questionnaire to assess Yin-Xu. Part II: evaluation of reliability and validity.Forsch Komplementmed. 2012;19:285-292.
Lee S, Park J, Lee H, Kim K. Development and validation of Yin-Deficiency Questionnaire.Am J Chin Med. 2007;35:11-20.
Langevin HM, Badger GJ, Povolny BK, Davis RT, Johnston AC, Sherman KJ, Kahn JR, Kaptchuk TJ. Yin Scores and Yang Scores: a new method for quantitative diagnostic evaluation in traditional Chinese medicine research.J Alternative and Complementary Medicine. 2004;10:389-395.
Ryu H, Lee H, Kim H, Kim J. Reliability and validity of a cold-heat pattern questionnaire for traditional Chinese medicine.J Altern Complement Med. 2010;16:663-667.
Seki M, Oie M, Ichihashi Y, Shida H. Hemadsorption and fusion inhibition activities of hemagglutinin analyzed by vaccinia virus mutants.Virology. 1990;175:372-384.
Chen RQ, Wong CM, Lam TH. Construction of a traditional Chinese medicine syndrome-specific outcome measure: the Kidney Deficiency Syndrome Questionnaire (KDSQ).BMC Complement Altern Med. 2012;12:73.
Wu D, Lai S, Zhou L, Guo X, Liang W, Wen Z, Ou A, Zhang G, Chen K. Further validation of the Health Scale of Traditional Chinese Medicine (HSTCM).Chin Med. 2009;4:8.
Wong W, Lam CL, Leung KF, Zhao L. Is the content of the Chinese Quality of Life Instrument (ChQOL) really valid in the context of traditional Chinese medicine in Hong Kong?Complement Ther Med. 2009;17:29-36.
O’ Donnell MP. Definition of health promotion.Am J Health Promot. 1986;1:4-5 [pmid: 10282523].
Kung HY. Brief discussion of categorization of BC.Zhongyiyao Xuebao. 2003;31:6.
Su SR, Zhong BL, Li X. Investigation of the body constitution type in 1061 children.Zhongyi Zazhi. 1996;37:613-616.
Li Y. Observation in the body constitution type of 225 Summer full-term healthy newborns.Hunan Zhongyi Xueyuan Xuebao. 1996;6:20-22.
Hu WJ. Study of the body constitution type.Hunan Zhongyi Xueyuan Xuebao. 1987;2:9-11.
Zhu JS. Clinical implication of the body constitution type in children.Xinzhongyi. 1989;21:6-8.
Wen ZY, Zheng J. Investigation of the body constitution type in children and symptom differentiation and treatment.Zhongyi Zazhi. 1998;39:362-363.
Kuang DY. Study of the body constitutional pathology.Chengdu Zhongyi Xueyuan Xuebao. 1978;1:3-17.
Ho YM, Gao QY, Yan QD. To explore the treatment principle of time and place according to the result of body constitution type study.Zhongyi Zazhi. 1986;27:47-50.
Pang WM. Discussion of the body constitution in eye disease.Liaoning Zhongyi Zazhi. 1985;9:13-15.
Qin DP. Discussion of the relationship between temperament and symptom differentiation and treatment.Guangxi Zhongyiyao. 1984;7:4-7.
Wang MM. Exploration of the body constitution type of newborns.Liaoning Zhongyi Zazhi. 1995;22:293-294.
Chen HZ. Clinical implication of the body constitution type of women.Guangxi Zhongyiyao. 1988;11:15-17.
Chen YC. Discussion of the body constitution in children and dietary care.Sichuan Zhongyi. 1998;16:9-10.
Wang Q. Status and prospect of Constitutional theory in traditional Chinese medicine.Zhongguo Zhongyi Jichu Yixue Zazhi. 2002;8:86-95.
Wang DP. Discussion on the body constitutional theory in Chinese medicine and the clinical implication.Yunnan Zhongyiyao. 1984;5:10-12.
Mu GC. The body constitutional theory in Chinese medicine and the alienation.Xin zhongyi. 1983;9:1-7.
Tian DH, Lu MW. Discussion of the body constitution and symptom pattern.Shandong Zhongyi Xueyuan Xuebao. 1983;7:7-11.
Niu BY. Study of the body constitution in patients with simple obesity.Guoyi Luntan. 2001;16:21-24.
Wang Q. Classification and diagnosis basis of nine basic constitutions in Chinese medicine.Beijing Zhongyiyao Daxue Xuebao. 2005;28:4.
Liu H, Zhang HJ, Tian JZ, Yan L, Chang SL, Zhou W, Yu XG, Sheng T, Chen B. Investigation into constitutions of patients with vascular dementia.Zhonghua Zhongyiyao Zazhi. 2006;21:148-150.
Zhang YY, Zhang HM, Guo DY, Wei X, Lin BR. Body constitution characteristics of ischemic stroke in 168 cases.Shanghai Zhongyiyao Zazhi. 2008;42:31-34.
Sun Y, Tong PJ, Xiao LW. Study on correlation between postmenopausal osteoporosis and TCM constitution of patients.Zhongyi Zazhi. 2009;50:696-698.
Liu YF, Wang SH, Chen BM, Liu GY, Zhou Q, Zhong LP. Study on constitution of traditional Chinese medicine and renal pathological features of 152 patients with IgA nephropathy.Jiangning Zhongyi Zazhi. 2013;40:15-17.
Song HP, He YM. Study on constitutional features of 476 cases of primary hypertension.Shanghai Zhongyiyao Daxue Xuebao. 2001;15:33-35.
Geo JJ, Wang XL, Xue JG, Wang YJ, Chen TJ. Characteristics of Chinese medical constitution of 328 patients with coronary heart disease.Shanghai Zhongyiyao Zazhi. 2010;44:76-77.
Liu ES, Sun ZT, Feng JH, Wang K. Clinical epidemiology of TCM syndrome and syndrome element in 1010 patients with bronchitis asthma.Tianjin Zhongyiyao. 2009;26:357-359.
Tang Y, Cheng Y, Wang YF, He P, Yang RJ. The primary study on the constitutions in 104 children with postinfectious cough.Yunnan Zhongyi Xueyuan Xuebao. 2010;33:36-38.
Wu YJ, So SN. Primary investigation of the type of body constitution in Chinese medicine for chronic insomnia.Guangdong Yixue. 2010;31:307.
Tam MH, Ng FW. Clinical study of body constitution in Chinese medicine for endocrine compound syndrome.Zhongguo Zhongyiyao Xiandai Yuancheng Jiaoyu. 2010;8:105-106.
Zhou XJ, Tian DF. Clinical survey on the distribution of constitutional pattern among cases of population at high risk susceptible to nasopharyngeal carcinoma.Zhongguo Zhongyi Jichu Yixue Zazhi. 2003;9:51-54.
Lin JD, Lin JS, Chen LL, Chang CH, Huang YC, Su YC. BCQs: a Body Constitution Questionnaire to assess stasis in traditional Chinese medicine.European Journal of Integrative Medicine. 2012;4:e379-e391.
Huber M, Knottnerus JA, Green L, van der Horst H, Jadad AR, Kromhout D, Leonard B, Lorig K, Loureiro MI, van der Meer JW. How should we define health?BMJ. 2011;343:d4163.
Liu K, Wang Q. A few questions related to dampness-heat body constitution research.Xin Zhongyi. 2009;41:3.
Russo VR. Seeley’s Anatomy & Physiology. 9th ed. New York: The McGraw Hill Company 2011; 950-952.
Maciocia G. The Foundations of Chinese Medicine a Comprehensive Text for Acupuncturists and Herbalists. 2nd ed. China: Elsevier Churchill Livingstone 2005; 3-17.
Wang Q. Traditional Chinese medicine will make new contributions to mankind in treating sub-health conditions in the 21th century.Beijing Zhongyiyao Daxue Xuebao. 2001;24:2.
Zhao X, Chen JX, Wang LM, Cui HT, Cui HZ, Kang CJ. The thinking on sub-health status and the relationship between disease and syndrome.Shandong Zhongyi Zazhi. 2010;29:739-749.
Stewart IB, Rojek AM, Hunt AP. Heat strain during explosive ordnance disposal.Mil Med. 2011;176:959-963.
Li WJ, Liu H, Xu MN. Classification of thermal environment and human ’s thermal health.Zhileng Yu Kongtiao. 2009;23:17-20.
Craven R, Hirnle C, Jensen S. Fundamentals of Nursing Human Health and Function. 7th ed. China: Wolters Kluwer Health/Lippincott Williams & Wilkins 2013; 319-320.
Ma T, Tan C, Zhang H, Wang M, Ding W, Li S. Bridging the gap between traditional Chinese medicine and systems biology: the connection of Cold Syndrome and NEI network.Mol Biosyst. 2010;6:613-619.
Ko GT, Chan JC, Chan AW, Wong PT, Hui SS, Tong SD, Chow F, Chan CL. Low levels of awareness of suboptimal health conditions in a high-risk working population: the “better health for better Hong Kong” health promotion campaign.Int J Behav Med. 2007;14:63-69.
Shen XH, Ruan JH, Ni HM, Pei CF, Yang SJ, Wang Y, Jiang J. The study on constitutional type of Chinese Medicine in 400 healthy young men.Liaoning Zhongyi Zazhi. 2010;37:2089-2091.
Cheng K, Wan CY, Fan WL. Primary study of body constitution type in Chinese medicine for healthy children.Zhongguo Yiyao Xuebao. 2000;15:41-42.
Zhang QX, Zheng XL. Discussion on pathogenesis and treatment of dampness constitution.Shanxi Zhongyi Xueyuan Xuebao. 2010;33:3-4.
Zhu YB, Wang Q, Wu CY, Pang GM, Zhao JX, Shen SL, Xia ZY, Yan X. Logistic regression analysis on relationships between traditional Chinese medicine constitutional types and overweight or obesity.Zhongxi yi Jiehe Xuebao. 2010;8:1023-1028.
Tong YS. Study of the relationship between dampness-heat body constitution and type 2 diabetes mellitus.Zhongyiyao Xuekan. 2004;22:1656-1657.
Lo MY. Dampness-heat body constitution and coronary heart disease-evaluation of the risk factors of coronary heart disease with Chinese medicine.Shandong Zhongyiyao Daxue Xuebao. 2003;27:16-20.
Lu M, Wang M, Chen W, Hu YM, Tan C. Study of the temperature on insufficiency of the kidney yang patient’s subjective and objective cold extremities.Gansu Zhongyi Xueyuan Xuebao. 2005;22:22-25.
Wang Q, Yao SL, Dong J, Wu HD, Wu CY, Xia ZY, Shi HF, Pang GM, Deng QW, Zhao JX. Changes of endocrine and immune function in subjects of yang deficiency constitution.Zhongxiyi Jiehe Xuebao. 2008;6:1226-1232.
Epstein Y, Roberts WO. The pathopysiology of heat stroke: an integrative view of the final common pathway.Scand J Med Sci Sports. 2011;21:742-748.
Lin SC, Chen MF, Li TC, Hsieh YH, Liu SJ. The distribution of Yin-Deficient symptoms and their relationship on survival rate in cancer patients with Yin-Deficiency.Am J Chin Med. 2008;36:655-663.
Song YZ, Ye RQ, Song QL, Ying JP, Cao Y, Peng JJ. Relationship between syndrome and constitution characteristics on 498 cases of primary hypertension patients.Zhongy yao Daobao. 2012;18:10-15.
Hu XJ, Yang XB, Wu WY, Long SQ, Deng H, Chai XS, He WF, Huang L, Liao GY, Zhou YS. The correlationship between Chinese medicine constitution patterns and TNM staging, Okuda staging of primary liver cancer.Shizhen Guoyi Guoyao. 2011;22:738-741.
Wang Q, Zhu YB, Origasa H, Du J, Pang GM, Song XH, Qian HN, Xue HS, Zhao JX. Study on related influencing factors of phlegm-wetness constitution in Chinese medicine.Beijing Zhongyiyao Daxue Xuebao. 2008;31:10-13.
Shen C, Pang SM, Kwong EW, Cheng Z. The effect of Chinese food therapy on community dwelling Chinese hypertensive patients with Yin-deficiency.J Clin Nurs. 2010;19:1008-1020.
Wu YM. Food and health: the impact of the Chinese traditional philosophy of food on the young generation in the modern world.Yingyan Yu Shipin. 1995;95:23-27.
Zhang WF, Zhang WR, Wei BB. Research overview of diet in regulating constitution.Zhonghua Zhongyiyao Zazhi. 2010;25:734-737.