The American Journal of Chinese Medicine, Vol. 47, No.

3, 495–506
© 2019 World Scientific Publishing Company
Institute for Advanced Research in Asian Science and Medicine
DOI: 10.1142/S0192415X19500253
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The Role of Chinese Medicine in Health

Maintenance and Disease Prevention:
Application of Constitution Theory
Am. J. Chin. Med. 2019.47:495-506. Downloaded from www.worldscientific.com

Lingru Li,*,a Haiqiang Yao,*,†,a Ji Wang,* Yingshuai Li* and Qi Wang*

*School of Traditional Chinese Medicine
Beijing University of Chinese Medicine
Beijing 100029, P. R. China
†Tang Center for Herbal Medicine Research and
Department of Anesthesia & Critical Care
Pritzker School of Medicine, University of Chicago
Chicago, Illinois 60637, USA

Published 26 April 2019

Abstract: Traditional Chinese medicine (TCM) has guided health maintenance and disease
treatment for thousands of years and has been widely used in many countries around the
world. TCM regards each individual as unique so all corresponding therapeutic and
preventive approaches in TCM are personalized. Personalized medicine, also referred to as
precision medicine, is an emerging medical paradigm that points toward a new direction for
future medical development. TCM constitution studies the holistic body condition, which is
affected by both inborn and acquired factors. Body constitution lays the foundation for
disease diagnosis, prevention and treatment. Different constitution types predispose indivi-
duals to different disease susceptibilities. Examining an individual’s unique body constitution
can promote effective health management and benefit the application of personalized med-
icine significantly. This review will introduce and discuss the application of the TCM
constitution for health maintenance and disease prevention. In last decade, a number of
modern techniques have been employed in the constitution research to evaluate the health
status of individuals. The TCM constitution reflects the current status and future trends of
human health in four aspects, i.e., individual differences, life processes, psychological
condition and adaptability to natural and social environments. This TCM constitution theory
has already been applied in the Chinese public health management at different levels with

Correspondence to: Dr. Yingshuai Li and Prof. Qi Wang, School of Traditional Chinese Medicine, Beijing
University of Chinese Medicine, No. 11 East Road North 3rd Ring Road, Chaoyang District, Beijing 100029,
P. R. China. Tel: (+86) 10-6428-6867, Fax: (+86) 10-6428-6867, E-mail: liyingshuai2013@163.com (Y. Li);
wangqi710@126.com (Q. Wang).
a
These authors contributed equally to this work.

495
 496 L. LI et al.

promising outcome. The constitution theory and practice provide a new approach for health
maintenance and disease prevention.
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Keywords: TCM Constitution; Personalized Medicine; Health Evaluation; Health Mainte-

nance; Disease Prevention; Review.

Introduction

The purpose of healthcare is not only to provide disease treatment but also maintain human
health. The health-based medicine model has attracted increasing attention over recent
Am. J. Chin. Med. 2019.47:495-506. Downloaded from www.worldscientific.com

years (Morley and Vellas, 2017; Rice and Sara, 2018). Many radical changes of the disease
spectrum such as high incidence of chronic diseases and rapidly growing medical expense
are highlighting the significance of public health (Berkowitz et al., 2018; Riley et al.,
2018). Managing a patient’s illness may not necessarily alleviate the patient’s suffering or
promote the patient’s wellness; therefore, more attention should be placed on promoting
the patient’s health instead of the traditional focus on treating diseases (Dubertret, 2006;
Mir and Kane, 2018).
To maintain health and prevent diseases, all health conditions need to be determined
first. Currently, the primary health measurement methods are physical examination, lab-
oratory studies and medical diagnosis, which aim for disease treatment not health main-
tenance. The Directory of Basic Physical Examination Items, issued by the Ministry of
Health of the People’s Republic of China, contains 59 primary items, such as routine
physical examination, surgical examination, urine test, X-ray examination, etc. (Associa-
tion, 2014). However, those measurements focus on the changes of the human body’s
physical structure; they are designed to examine whether individuals have diseases but
cannot determine an overall status of health. Further methodologies and approaches are
needed to achieve personalized health maintenance and disease prevention.
Traditional Chinese medicine (TCM) has been used for thousands of years of history as
a form of health management, and this health care system has been widely used in many
countries of the world (Kiyama, 2017; Li et al., 2017b; Liao et al., 2017; Wu et al., 2018;
Zhao et al., 2018). TCM constitution refers to the holistic body condition, which affects
how you feel and behave, and how your body responses to pathogenic factors (Hou et al.,
2017; Yu et al., 2017b). The formation of constitution is affected by both inborn and
acquired factors (Yao et al., 2018). In China, the TCM constitution has already been
applied in public health management at a national level and proved to be fruitful (Wang
et al., 2015a). In this review, we discuss the application of TCM constitution in body
condition evaluation, health maintenance and disease prevention.

TCM and Personalized Medicine

TCM regards each individual as distinct from others. Focused on the uniqueness of an
individual’s condition, all the corresponding therapeutic and preventive approaches in
 TCM CONSTITUTION THEORY AND HEALTH MAINTENANCE 497

TCM are personalized (Wang et al., 2012, 2018). Syndrome differentiation is the core
principle of TCM in clinical practice (Ong et al., 2017; Ying et al., 2018). As a certain
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stage of a disease, the syndrome is dynamic and diagnosed according to the patient’s
comprehensive response of pathogenic, climatic, geographical, emotional and dietary
factors. Syndrome is typically used to determine a therapeutic strategy and then prescribe
formulas. In the eyes of a TCM doctor, every patient is different, so patients diagnosed with
the same disease but different syndromes may get different prescriptions. Thus, in TCM,
tailored therapeutic regimens are provided in accordance with an individual’s unique body
condition, echoing the philosophy of the newly proposed personalized medicine (Zhang
et al., 2012; Wang and Zhang, 2017).
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TCM constitution theory provides a typology system to classify individuals into dif-
ferent groups based on their body types (Wang et al., 2016a). Body constitution lays the
foundation for diagnosis, treatment and disease prevention. If a disease is like a tree, then
the body constitution is equivalent to soil, and different constitution types
predispose individuals to different disease susceptibilities (Wang et al., 2015b). Through
examining an individual’s unique body constitution, one can promote a more effective
disease treatment and prevention, which benefits the clinical practice of personalized
medicine significantly.
The TCM constitution can reflect an individual’s current health status and future health
trends in four aspects: physical differences, life processes, psychological condition and
adaptability to natural and social environments. For instance, phlegm-dampness is a basic
constitution type. Individuals with this constitution type usually have an over weight body
shape and a mild and calm personality; in addition, they may show poor adaptability to a
humid environment and may easily suffer from obesity, diabetes or other metabolic dis-
eases (Li et al., 2017a; Yao et al., 2018). Therefore, TCM constitution contributes to a
better understanding of a patient’s overall body condition and provides useful information
for disease prediction and prevention (Wang et al., 2016a). In China, the TCM constitution
has already been applied and proven to be fruitful to public health management at a
national level. It may provide a new approach to health maintenance and disease
prevention, helping to translate personalized medicine from promise to practice (Wang
et al., 2016c).
Personalized medicine, in respect to modern Western medicine therapy, is referred to as
precision medicine, an emerging medical paradigm which proposes the customization of
healthcare (de Vries et al., 2018). The concept of personalized medicine was derived from
the variability of drug response of different individuals; the response could be affected by
genetics, nutrition, age, environmental exposure or many other factors (Vogenberg et al.,
2010). The aim of personalized medicine is to provide tailored medical treatment to the
right patient at the right dose. This new medical model promises to improve the efficiency
of the health care system by determining treatment more quickly, pinpointing an optimal
dose, and preventing adverse effects for the individual (Snyderman et al., 2016). Inter-
estingly, the principle behind this modern medicine model can also be applied to the TCM
constitution theory.
 498 L. LI et al.

General Health Evaluations

Health is a state of complete physical, mental and social well-being and not merely the
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absence of disease or infirmity (Organization, 1946). Officially issued by the WHO,

this definition of health was a great progress compared to former definitions, which solely
stressed on the absence of disease. Much like the definition of health, we should put
forward a concept that focuses on the status of health. Status is a commonly used concept
in systems science that refers to the observable and identifiable states, trends and features of
a system (Silverman, 2018). Health can be judged and evaluated based on the status of
body performance, namely, health status. Health is a result of the integration and coordi-
nation of multiple organs and systems that cannot be explained merely by the function of
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any single organ. The health evaluation system should integrate the function and structure
comprehensively.
According to the updated definition of health, it has been suggested that health not only
includes the absence of disease, but also physical, mental and social status of the
person (Fang et al., 2017; Yu et al., 2018). Therefore, objective examination of biological
indicators cannot meet the requirements of a health evaluation. Aside from the fact that the
objective medical diagnosis data are transplanted into health evaluation, the subjective
health concept has also been gradually valued. Health covers not only physiology, psy-
chology and social adaptation but also biological and abiotic environments. Moreover, an
individual’s ability to adapt to a social and natural environment is a key factor for eval-
uating his or her health status. Subjective health evaluation is mainly stated in the form of
health rating scales, adopting a rating scale (e.g., 1–5 points) or a classification rating
(by negative/positive categories). At present, the components of a health rating scale often
cover five aspects: physical health, mental health, social health, self-assessed health and
quality of life (Keszei et al., 2010; Burgard and Chen, 2014). Since the 1990s, subjective
health indicators have been extensively studied, and literature shows that self-rated health
may serve as a reliable indicator of health status (Dasbach et al., 1994; Schoenfeld et al.,
1994). However, some scholars cast doubt on subjective health measurement because of
the existence of large bias with variations of population and time. A major cause of such
bias is the separation of the current subjective measurement and objective measurement,
which have not been interlinked. Based on the above issues of health evaluation, we
propose that the health evaluation system should reflect the combination of the subjective
and objective health situation.
Since ancient times, a Greek medical scientist (460–370 B.C.) and the Inner Canon of
the Yellow Emperorfrom the Qin and Han Dynasties in China (around 200 B.C.) have both
taken the differences in individual constitutions as an important topic in the field of health
care. In the modern era, significant developments in genomics emphasized the importance
of individualized medicine. In 2005, the international HapMap project achieved impres-
sive results (The International HapMap et al., 2005). It became possible for us to predict
and prevent diseases through individual gene variations (Evans and Relling, 2004; Relling
and Evans, 2015). However, the high cost of a gene test impeded the spread of the
individualized diagnosis and treatment.
 TCM CONSTITUTION THEORY AND HEALTH MAINTENANCE 499

With the completion of the Human Genome Project, P4 medicine which emphasizes
people foremost and prevention-oriented medicine has quietly emerged (Pack, 2016;
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Marcum, 2017). P4 is an acronym for preventive, predictive, personalized and participa-

tory. The P4 medicine stresses the importance of the diversity of individuals and marks the
arrival of a new era of individualized medicine (Pulciani et al., 2017).
In contrast to ancient TCM, a constitution theory was introduced by Prof. Qi Wang in
the 1970s. The constitution theory proposed a new concept of health: health refers to
a harmonious state of an individual to concordantly adapt to the natural and social
environments, both physiologically and psychologically during the life-long process
(Wang et al., 2016b).
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Health Evaluation System Based on the TCM Constitution

The modern constitution theory focuses on the intrinsic features of the human body. These
features include both inherited and acquired features such as morphological structure,
physiologic function and mental status, etc. (Wang et al., 2016a). The constitution of
human body is comprehensive and relatively stable; it manifests the personalities generated
in the process of growth and development of the human body and is also adaptive to the
natural and social environment.
By means of adopting modern rating scale evaluations, modern molecular biological
and biophysical techniques, a four-dimensional measurement and evaluation system of
health status has been established based on TCM constitution. To dateCthe evaluations for
the nine constitution types (or a portion of them) with multiple techniques have been
developed.

Subjective Scale Evaluation for TCM Constitution

The subjective rating scale for the TCM constitution is the core of the constitutional health
evaluation system. TCM constitution, guided by TCM theories, classifies humans into nine
constitution types according to physiological and psychological features and adaptive
capacity, i.e., balanced constitution, qi-deficiency constitution, yang-deficiency constitu-
tion, yin-deficiency constitution, phlegm-dampness constitution, damp-heat constitution,
blood stasis constitution, qi stagnation constitution and an inherited special constitution
(Wang et al., 2016a).
The adult edition of the Rating Scale for 9 TCM Constitutions has 60 evaluation items
for a self-rating scale. Each item has a rating scale of 1 to 5 points (1 point for healthy, 2
points for a bit unhealthy, 3 points for occasionally sick, 4 points for frequently sick, etc.).
The “Classification and Identification Criterion of TCM constitution” has been promul-
gated by the China Association of Traditional Chinese Medicine at April 9, 2009 (Medi-
cine, 2009). The application of this classification and identification method in a nationwide
epidemiological investigation of 21,948 subjects has proved the existence of nine consti-
tution types, and other research has also validated this theory (Wong et al., 2013). Among
all the subjects evaluated, the balanced constitution accounted for 32.75%. By percentage,
 500 L. LI et al.

the top four constitutions were qi-deficiency constitution, damp-heat constitution,

yin-deficiency constitution and qi-stagnation constitution (Wang and Zhu, 2009). Besides
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the Chinese version, Japanese and English editions have also been published to promote
the internationalization of the TCM constitution (Zhu et al., 2006; Jing et al., 2012). The
Korean edition is undergoing a reliability and validity evaluation.
To perform the health status evaluation for different age groups, different editions of the
TCM constitution rating scale have been developed. The adult edition of the Constitution
Rating Scale covers the range of 18–65 years old. Based on the adult edition and combined
with the characteristics of the elderly, the Constitution Rating Scalefor the Elderly
(65 years and older) has been developed. This edition contains 33 items and is highly
Am. J. Chin. Med. 2019.47:495-506. Downloaded from www.worldscientific.com

valued by the Chinese State Administration of Traditional Health, National Health and
Family Planning Commission. The rating scale for children (6–12 years old) is still under
development. The TCM constitution identification has been listed in the National Basic
Public Health Service Standards issued by the National Health Commission of the
People’s Republic of China since 2009. The constitution rating scale has been widely used
in China and serves as an effective method to achieve health management and disease
prevention (Li et al., 2018; Liu et al., 2018; Yao et al., 2018).

Evaluation of Psychological Dimension

A constitution is a combination of specific physical qualities and certain psychological

diathesis. Some physical qualities always correspond to certain mental dispositions.
Psychological evaluation rating scales, such as the Eysenck personality questionnaire
(EPQ-RSC) and the NEO-FFI-R Personality Questionnaire, have been employed in the
health status evaluation of nine constitution types (Tang et al., 2012). There are proven
positive correlations between the constitution types and psychological characteristics. In
other words, each constitution type is prone to certain psychological characteristics, which
is a result consistent with the TCM constitution theory that the body and spirit function as
an undivided whole. In the extraversion–introversion dimension, the balanced constitution
type got the highest score, and the qi-stagnation constitution type got the lowest score. The
proportion of introversion in the phlegm-dampness constitution population was high,
showing a significant difference with the balanced constitution. This phenomenon indicates
that the phlegm-dampness constitution is characterized by introversion and emotional
homeostasis. People with different constitution types have demonstrated that the corre-
sponding psychological characteristics through the TCM constitution identification can
also serve as a psychological status evaluation (Tang et al., 2012).

Evaluation of the Adaptability to the Natural and Social Environment

Different constitution types have different levels of adaptability to the social and natural
environment. The constitution types are relevant to health-related life quality evaluation as
shown in the revised Health Questionnaire SF-36. This enables the comprehensive anal-
ysis of the health status and the adaptability of the human body to the natural and social
 TCM CONSTITUTION THEORY AND HEALTH MAINTENANCE 501

environment from the perspective of physiology, psychology, sentiment, social function

and other subjective feelings (Lam et al., 2012).
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Studies on the relevance of constitution and SF-36 in the TCM constitution-based

health status evaluation revealed that eight biased constitution types may affect other
aspects of quality of life. For instance, the Qi-stagnation constitution mainly affects vigor,
social function, emotional function, mental health, psychology and physiology; its wide
range of negative effects are likely related to fierce competitions in today’s society (Wang
et al., 2007). Inherited special constitution mainly refers to allergic constitution. According
to investigations, such constitution mainly affects the social functions of life. Qi-deficiency
constitution is characterized by feeble breath and organ dysfunction caused by the insuf-
ficient primordial Qi, which easily hinders daily physical activities. This has implications
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for evaluating whether health status may hinder normal physiological activities. Yang-
deficiency constitution may affect the tolerance to pain and hinder daily activities which
may cause body pain (Wang et al., 2007).

Evaluation of Physiological Differences

Biological dimension is a macroscopic concept of the objective constitution evaluation

indicators, mainly including macro-features of the tongue and face, physiological indica-
tors and biochemical indicators, etc.
Exterior features. Based on the relevant descriptions of TCM constitutions in ancient
and modern literature, the research group headed by Prof. Qi Wang summarized the macro-
features of the nine constitution types, including physique, skin color and texture, tongue,
and complexion, etc. (Zhang et al., 2016; Hou et al., 2017). A three-dimensional simulative
model for the nine constitution types has been developed based on the information of
above-mentioned macro-features. For instance, qi-deficiency constitution is characterized
by pale or sallow complexion, blank eyes, inability to taste, pale lips, flabby muscles and
lassitude. The three-dimensional simulation system provides a visual description and dy-
namic demonstration of the detailed exterior features of TCM constitution which will
promote the academic communication and standardization (Liu, 2007).
Parameters during sleep. Four constitution types including balanced, phlegm-
dampness, yin-deficiency and yang-deficiency constitutions were evaluated by physio-
logical parameters during sleep. According to this study, the four constitution types
demonstrated different physiological features during this process. For example, yin-defi-
ciency constitution demonstrated worse sleeping hours, deep sleep percentage and sleeping
efficiency compared with balanced constitution; this constitution type also showed higher
percentages of the light sleep, longer awakening time, faster heart rate and higher risk of
suffering from insomnia. Phlegm-dampness constitution was better than balanced consti-
tution in the light sleep percentage and awakening time but poorer in the deep sleep
percentage and sleeping efficiency. Phlegm-dampness constitution also showed a
higher apnea–hypopnea index (AHI) and a lower blood oxygen saturation (LSaO2), which
indicated a higher risk of obstructive sleep apnea-hypopnea syndrome (OSAHS)
(Yan, 2011).
 502 L. LI et al.

Biochemical indicators. A comparison of the yang-deficiency, yin-deficiency and

balanced constitution types in the endocrine and immunologic function status was con-
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ducted. Results revealed that physiological characteristics were consistent with their con-
stitution types. Yang-deficiency constitution, compared with balanced constitution, showed
substantially decreased serum levels of lactic acid, low density lipoprotein, N-acetyl gly-
coprotein, fatty acid and unsaturated fatty acid; but had increased serum levels of phos-
phatidylcholine and high-density lipoprotein. Meanwhile, yang-deficiency constitution also
showed significantly decreased urine creatinine level and increased urine levels of lactic
acid, dimethylamine, citric acid, and hippuric acid. All of the physiological features are
consistent with the characteristics of the yang-deficiency constitution (Wang et al., 2008).
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Metabonomic characteristics. Metabolomics analysis of blood and urine samples from

yang-deficiency, yin-deficiency and balanced constitution types showed that different
constitution types had different metabolic pathways and metabolic characteristics. Yang-
deficiency and yin-deficiency were different in the aspects of energy metabolism, immu-
nologic function, endocrine hormone and cyclic nucleotide system, etc. with different
metabolic markers (Li et al., 2011).

Evaluation of Genetic Differences

Single nucleotide polymorphisms (SNP). SNP examination revealed the specific gene
loci of the phlegm-dampness, yin-deficiency and yang-deficiency constitution types.
The presence of relevant physiologic functions proved that the TCM constitution had a
molecular biological basis, and it also laid the foundation of microscopic identification of
TCM constitutions (Wu et al., 2010).
mRNA expression profiling. On the basis of the classification of the nine constitution
types, a high-throughput genomic detection technology was adopted to explore the genetic
basis of the TCM constitution (Yu et al., 2017a). The results revealed the different genetic
characteristics and helped to interpret the predispositions of each constitution type
(Li et al., 2017a). For instance, yang-deficiency constitution showed decreased gene ex-
pression of thyroid hormone receptor beta (TRβ), steroid receptor coactivator 1 (SRC1) and
steroid receptor coactivator 3 (SRC3) providing a molecular explanation of cold intoler-
ance symptom of yang-deficient constitutions (Wang and Yao, 2008).
Protein expression profiling. Serum protein mass spectrometry technology was
employed to describe the unique protein profiling of different constitution types. Obesity
subjects with phlegm-dampness constitution, compared with the other obesity groups, were
found to have a higher expression levels of LARGE in serum protein, and lower protein
expression levels of DNA-independent protein kinase catalytic subunits and FBW1A. The
results indicated a differential protein expression profiling of phlegm-dampness constitu-
tion (Yu et al., 2014).
DNA methylation. Genome-wide DNA methylation analyses were conducted to explore
the molecular features of phlegm-dampness constitution. A total of 288 differentially
methylated probes (DMPs), compared with balanced constitution, were located. According
to the DMPs, the corresponding genes were also mapped, and some of these were
 TCM CONSTITUTION THEORY AND HEALTH MAINTENANCE 503

metabolic-related. SQSTM1, DLGAP2 and DAB1 indicated diabetes mellitus; and

HOXC4 and SMPD3 indicated obesity. This research suggested the potential risk for
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metabolic disorders in phlegm-dampness constitution (Yao et al., 2018).

Summary and Perspectives

A health evaluation is different from the diagnosis of disease. With personalization as the
core concept, the TCM constitution subjective scale evaluation technique has been de-
veloped, which could cover multiple age groups including the elderly and children. This
approach serves as a health status evaluation method, which predicts the disease risks of
Am. J. Chin. Med. 2019.47:495-506. Downloaded from www.worldscientific.com

each constitution type to achieve health maintenance and early disease prevention.
Various techniques were employed to complement and validate the TCM constitution
evaluation method. This constitution-based system can conduct a multi-dimensional
evaluation of different aspects of health, such as psychological evaluation, natural and
social adaptability evaluation, biological evaluation and genetic evaluation, etc. (Wang
et al., 2011). Thus, TCM constitution can provide a comprehensive perspective on the
current status and future trends of health and achieve the health evaluation with observable,
measurable and recognizable outcomes.
This TCM constitution evaluation system has already been applied in the public
health services and health management across China and achieved remarkable results
(Wang et al., 2016a). TCM constitution is a holistic and patient-centered system which is
also consistent with the concept of P4 medicine (Vogt et al., 2016; Marcum, 2017). TCM
constitution could help to promote the combination of health evaluation and health man-
agement and achieve public health maintenance. With the help of the Internet and the
rapidly evolving information technology sector, a new pattern of constitution-based health
management is being carried forward. The originality and innovative strengths of TCM
constitution should facilitate further development of health maintenance and disease
prevention for different age groups and nationalities.

Acknowledgments

This work was supported by grants from the China Postdoctoral Science Foundation
(2017M610830) and National Natural Science Foundation of China (81803970).

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