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Different traditional Chinese medicine constitution is associated with dietary and lifestyle behaviors among adults in Taiwan

The World Health Organization states prevention of chronic diseases should be based on good lifestyle behaviors and healthy diets as they can reduce the risk of chronic diseases by 80%. The theory of traditional Chinese medicine constitution (TCMC) emphasizes the congenital differences of TCMC stem from the genes of parents, while acquired differences in TCMC are caused by factors as living environments, lifestyle behaviors, and dietary habits. From the perspective of preventive medicine, this study explores the correlation between dietary habits and lifestyle behaviors as potential risk factors for different types of TCMC—balanced constitution, Yang deficiency, Yin deficiency, and Phlegm stasis. Research data were collected from 2760 subjects aged 30 to 70 years participating in a survey conducted by Taiwan Biobank in 2012 to 2017. The survey included basic demographic characteristics, lifestyle behaviors, and dietary habits along with a Body Constitution Questionnaire. Compared to men, women were 3 to 4 times more likely to develop Yang-deficiency, Yin-deficiency, and Phlegm stasis. Variables that affected TCMC were smoking, midnight snack consumption, consumption of gravy-soaked or lard-soaked rice/noodles, deep-fried soybean products, bread spread, pickled vegetables as side dishes for the main course of a meal, and the dietary habit of vegetables or fruits instead of high-fat desserts. Poor dietary habits and lifestyle behaviors are the cause of unbalanced TCMCs. Understanding the specific TCMC of individual can provide useful information and predictions to maintain physical health and achieve early disease prevention to meet the goal of preventive medicine.


Introduction
Dietary habits and lifestyle behaviors are key factors influencing health. The Western pattern diet and refined foods are positively correlated with an elevated incidence of chronic disease including cardiovascular disease, colon cancer, diabetes, obesity, and metabolic syndrome, [1,2] and chronic diseases accounted for 71% of global deaths in 2015. [3] For chronic diseases, the rise in prevalence at a young age is not a sign of aging but rather results from poor lifestyles such as smoking, lack of exercise, obesity, alcoholism, or poor dietary habits such as reduced consumption of vegetables, fruits, nuts, whole grains, beans, fish, and low-sodium foods. [2] The World Health Organization stated that the good lifestyles and healthy diets can reduce the risk of developing chronic diseases by 80%. [4] Traditional Chinese medicine (TCM) is a commonly used complementary and alternative medicine that has proven effective for chronic disease prevention and treatment. [5] The theory of TCM constitution (TCMC) is a branch of TCM emphasizing that congenital differences in TCMC stem from the genes of the parents, while acquired differences in TCMC are caused by factors such as living environments, lifestyle behaviors, and dietary habits. [6] According to the TCMC theory originated in the Yellow Emperor's Canon of Medicine dated 2000 body constitution, which elaborates on the theoretical basis of TCM and explains the basic principles of TCM using the theory of Yin and Yang and the 5-element theory. [7,8] The TCMC theory states that the circulation of qi maintains the physiological functions of the body, the body balance is maintained through the complementary relationship between Yin and Yang, diseases result from Yin-Yang imbalance and interruption of qi. [8] The TCMC scale developed by Taiwanese researchers enables the systematic classification of constitution into 4 types (Yin deficiency, Yang deficiency, Phlegm stasis, and balanced constitution), with different constitutions exerting different influences on physiological characteristics, disease susceptibility, and disease progression. [6] Body Constitution Questionnaire (BCQ), an effective and useful tool, has been developed for evaluation of the composition of Yin deficiency, Yang deficiency, and Phlegm stasis. [9][10][11][12][13] The TCM theory advocates that a healthy lifestyle should be based on a good understanding of TCMC and that the TCM theory should be used to correct misconceptions about health and lifestyle behaviors. [14] TCMC is a relative variable in the life process and a key influencing factor of diseases. [15] Individualspecific recommendations for improving lifestyle behaviors to maintain and improve physical health should be made by using the combination of 5-element and Yin-Yang theories with a focus on maintaining the internal balance of the body based on individual-specific TCMC, cold-heat pattern, and emotion. [16,17] The TCMC theory states that only a balanced constitution represents a healthy body state, unbalanced body states that may be highly susceptible to some diseases. [18] To date, TCM still fails to have a clear definition of composite, and the treatment mechanisms are ambiguous, leading to questioning, criticism, and challenge. [8] Thus, high-quality studies are needed to confirm the close correlation between TCMC and chronic diseases. This study aimed to clarify the correlation between dietary habits and lifestyle behaviors as potential risk factors according to different body constitution types (balanced constitution, Yang deficiency, Yin deficiency, and Phlegm stasis).

Data source and sample
This was a cross-sectional study design. Between 2012 and 2017, we collected from 2760 subjects who participated in a survey conducted by Taiwan Biobank (TWB). After excluding subjects with a body mass index (BMI) below 18.5 kg/m 2 and those failing to provide relevant information. They were frequency-matched at a ratio of 1:1 by age, gender, and BMI. The TWB aims to build a nationwide research database that integrates genomic/ epigenomic profiles, lifestyle patterns, dietary habits, environmental exposure history, and long-term health outcomes of 300,000 residents of Taiwan. [19,20] Data were obtained from the TWB, a national biobank accessible to researchers that contains health information collected from Taiwan residents aged 30 to 70 years between 2008 and 2017. Clinical studies with TWB carried out in Taiwan have shown encouraging results, and it has been widely used in studies involving chronic diseases. [21][22][23][24]

Measurements
The survey contents comprised basic demographic characteristics and lifestyle behaviors (alcohol consumption, cigarette smoking, betel nut consumption, exercise habits, tea or coffee drinking, vegetarian diets, midnight snack consumption, and dietary supplement use). Dietary habit information was collected using the questionnaire designed for the Nutrition and Health Survey in Taiwan, [25] which comprised 17 questions about the dietary status within the last month. Each question was constructed using appropriate frequency and intensity scale descriptors and scored on a 5-point Likert scale with answer choices of "like this," "mostly like this," "fifty-fifty," "mostly not like this," and "not like this at all." The subjects were also administered a TCMC survey.
This study adopted the BCQ, developed by a TCMC and syndrome research team in Taiwan. [9][10][11][12][13] The BCQ was used to measure the psychological and physiological states of deviations in body constitution in each patient during the past month. The BCQ comprised 44 questions about 3 constitution types: Yang deficiency, Yin deficiency, and Phlegm stasis, with each question constructed using appropriate frequency and intensity scale descriptors and scored on a 5-point Likert scale. If the total score of a subject satisfied the identification criterion of a constitution, the subject was considered to have that constitution. That is, the 19 Yang deficiency questions scored ≥ 31 points means Yang deficiency and the 19 Yin deficiency questions scored ≥ 29.5 points means Yin deficiency; the 16 Phlegm stasis questions scored ≥ 27 points means Phlegm stasis. The final score of each constitution type was calculated by summing the scores of all items of each subscale, with a higher score implying a greater deviation from the constitution balance. Yang deficiency, Yin deficiency, and Phlegm stasis are unbalanced constitutions [9][10][11][12][13] ; if the total score of a subject failed to meet any of the criteria, the subject was considered not to have a single type of TCMC and to instead have a balanced constitution. The Cronbach α coefficients and intra-group correlation coefficients for Yang deficiency, Yin deficiency, and Phlegm stasis were 0.88 and 0.91, [9,10] 0.85 and 0.91, [11,12] and 0.88 and 0.91, [13] respectively.

Ethical consideration
Recruitment of individuals in the TWB project was performed in accordance with relevant regulations and guidelines, and the present study was approved by the Institutional Review Board of Kaohsiung Veterans General Hospital in Taiwan (VGHKS18-CT6-03).

Statistical analysis
Data analyses were performed using IBM SPSS Statistics (version 22.0, Inc, Chicago, IL) software. The variables analyzed in the study included TCMC (Yang deficiency, Yin deficiency, Phlegm stasis, or balanced constitution), age, sex, marital status, living alone or not, education level, and BMI, as well as lifestyle behaviors including alcohol consumption, cigarette smoking, betel nut consumption, exercise habits, tea drinking, coffee drinking, vegetarian diet, midnight snack consumption, and dietary supplement use. Dietary habits were classified into 3 frequency categories: "rare," "occasional," and "frequent" consumption. Stepwise regression analysis was performed to explore the effects of dietary habits and lifestyle behaviors on TCMC. P < .05 indicated statistical significance.
This study revealed the significant effects of dietary habits on the occurrence of a given type of TCMC. Subjects who frequently ate gravy-soaked or lard-soaked rice/noodles, deep-fried soybean products, occasionally or frequently ate bread spread, occasionally ate pickled vegetables as side dishes for the main course of a meal, and occasionally or frequently ate low-sodium products were more likely to develop Yang deficiency than those who rarely did. Subjects who occasionally or frequently ate gravy-soaked or lard-soaked rice/noodles, deep-fried soybean products, occasionally ate at least 2 kinds of vegetables in a day, occasionally or frequently ate stir-fried dishes and occasionally low-fat foods instead of general products were more likely to develop Yin deficiency than those who rarely did. Subjects who occasionally or frequently ate gravy-soaked or lard-soaked rice/ noodles, bread spread, occasionally ate at least 2 kinds of vegetables in a day and occasionally or frequently ate low-sodium products were more likely to develop Phlegm stasis than those who rarely did.

Discussion
This study explored the relationship between basic demographic characteristics, lifestyle behaviors, and dietary habits of subjects and their TCMC. After adjusting for age, BMI, sex, lifestyle habits, supplements, and dietary habits, the analysis revealed that dietary habits and lifestyle behaviors were predictors of TCMC. Factors with significant negative effects on the occurrence of balanced constitution were positively correlated with the occurrence of Yang deficiency, Yin deficiency, and Phlegm stasis.
At present, the most widely used instruments for classification of constitution types include, among others, the Constitution in Chinese Medicine Questionnaire, which was developed in Mainland China, [26] and the BCQ, which was developed in Taiwan. [9][10][11][12][13] Although Mainland China is very similar to Taiwan, the lifestyle, language, and culture are different. [27] Compare to Constitution in Chinese Medicine Questionnaire, this questionnaire is easily administered and its reliability and validity have been established in quite a few studies. [12,28,29] The analysis revealed younger age to be associated with an increased likelihood of developing Yang deficiency or Phlegm stasis, a finding similar to those of a Hong Kong-based study by Sun et al [30] that age is a preventive factor for Yin deficiency, Phlegm stasis, qi deficiency, and Wetness-heat constitution. This may be attributed to the fact that Yang and qi gradually decline with age; moreover, the older the age, the less likely individuals are to engage in heavy work and face various work-related pressures, thereby alleviating qi and Yin deficiency. Heli et al [31] investigated the health status of young people with different TCMC types, reporting that under the pressure of heavy work and economic conditions, more and more young people have suboptimal health status, meaning they are in a borderline state between healthy and diseased states. Heli et al [31] also reported that 31.19% of men have a balanced constitution, compared to about 20% of women; Lee et al [32] also showed a higher proportion of unbalanced constitutions in women than that in. These reports are consistent with the finding of this study that female subjects were 3 to 4 times more likely to develop unbalanced constitutions compared to male subjects, which may be attributed to the physiological characteristics and personalities of women. [33] Regarding lifestyle behaviors, data analysis revealed that subjects with Yang deficiency had a low BMI on average and that those who did not have an exercise habit had Phlegm stasis. The most obvious features of individuals with Yang deficiency are feeling cold, low subcutaneous fat, and low BMI. [30,34] In addition, most of the subjects who did not have an exercise habit exhibited Phlegm stasis, a finding consistent with the notion in the TCM theory that exercise can facilitate the flow of qi to eliminate qi deficiency and prevent Phlegm stasis. [30] This study also found that subjects who smoked cigarettes or ate midnight snacks were 1.8 and 1.5 times more likely to develop Phlegm stasis than those without, respectively. Cigarette smoking is well known to harm health and individuals who smoke cigarettes are more likely to with Yang deficiency, Yin deficiency, and Phlegm stasis, while individuals who eat midnight snacks are prone to Yang deficiency and Phlegm stasis. [30] Phlegm stasis is a basic type of constitution usually characterized by poor lifestyle behaviors such as cigarette smoking, irregular sleep, broiled food consumption, and limited physical activity. Individuals with this constitution are prone to obesity, diabetes, and other metabolic diseases. [35] Another finding of the present study was that subjects without a habit of drinking tea were prone to Yin deficiency. Individuals with Yin deficiency often present with a number of subjective symptoms such as thirst, dry eye, hot flush, constipation, small urine volume, rapid heart rate, and a higher risk of insomnia. [17,31,36] Tea contains caffeine, theophylline, and other alkaloids, all of which can excite the central nervous system; thus, individuals with Yin deficiency opt to drink tea less frequently to avoid insomnia. However, some studies have pointed out that drinking an appropriate tea may help to relieve depression, overcome sleep problems, and improve digestion. [6,37] As shown above, insights into TCMC can provide useful information for the adjustment of lifestyle behaviors such as the use of appropriate tea products, to alleviate body constitution.
Dietary habits can influence the sufficiency or deficiency of qi, blood, Yin, and Yang via the transportation and transformation functions of the spleen and stomach, thereby forming stable functional trends and constitutional characteristics. [38] The results of the present study revealed the significant impact of dietary habits on different TCMC types; that is, subjects with balanced constitutions had healthier dietary habits, while subjects with Yang deficiency, Yin deficiency, and Phlegm stasis frequently ate deep-fried products, bread spread, pickled products, stir-fried dishes, and low-sodium products with rare consumption of vegetables or fruits to replace high-fat desserts. Similarly, Jiang et al [39] also reported a negative correlation between the occurrence of a balanced constitution and individuals who liked meat products and disliked vegetables show a negative correlation. As shown above, individual differences, lifestyle behaviors, and dietary habits all affect TCMC and serve as important factors to alleviate Yang deficiency, Yin deficiency, and Phlegm stasis. [40] Selecting an appropriate treatment or recuperation method is key to maintaining a balanced constitution. However, this study had several limitations. For example, the survey of tea drinking habits focused on whether tea leaves or tea ingredients were contained in the drinks (excluding flower tea) but did not collect information about individual preferences for tea types; secondly, specific occupational and disease data were not collected, which may have affected the objectivity of the results. The current findings of this study, however, confirm the effects of dietary habits and lifestyle behaviors on TCMC.

Conclusions
Factors such as dietary habits and lifestyle behaviors can cause individual differences in TCMC. Understanding the influencing factors of TCMC for a given individual will provide useful information to maintain balanced constitution and health. Such understanding plays an indispensable role in health promotion and treatment of preventive medicine. Table 3 Stepwise regression analysis for demographic characteristics, dietary habits, and lifestyle behaviors and associations with TCMC. Adjusting for age, BMI, sex, lifestyle behavior, and dietary habits. AOR = adjusted odds ratio, BMI = body mass index, CI = confidence interval, TCMC = traditional Chinese medicine constitution. *P < .05. **P < .01. ***P < .001.