Chin J Integr Med
•1•
TRADITIONAL MEDICINE Research on Constitution of Chinese Medicine and Implementation of Translational Medicine WANG Ji (王
济)△, WANG Ting (王 停)△, LI Ying-shuai (李英帅), ZHENG Yan-fei (郑燕飞), LI Ling-ru (李玲孺), and WANG Qi (王 琦)
ABSTRACT Translational medicine is a new concept presented in recent decades, the core of which is to build a bridge between basic medical research and clinical application. From the beginning of constitution of Chinese medicine, clinical application has been given priority. Therefore, the idea of translational medicine is fully demonstrated in the research into the three key scientific problems of "classification of constitution of Chinese medicine", "relationship between constitution and disease" and "adjustment of constitution". Under its guidance, not only was the systematic theory of constitution of Chinese medicine established, but also the Constitution of Chinese Medicine Scale and the Standards of Classification and determination of Constitution of Chinese Medicine were developed, which translates methods of classifying the nine constitutional types into guidance for prevention of disease, management of health and clinical application. The research findings of constitution of Chinese medicine have been applied in clinical practice and public health, establishing the diagnosis and treatment model of constitution-disease-syndrome differentiation. The nationwide application of constitution differentiation has shown good effect. In the future, constitution of Chinese medicine should strengthen the evidence-based research and multi-disciplinary cooperation, and establish a research team on comprehensive constitution of Chinese medicine and translational medicine, to translate the findings into clinical practice and public health more accurately and quickly. KEYWORDS constitution of Chinese medicine, translational medicine, implementation
Translational medicine, also called translational research, is a new international concept presented in the field of medicine to overcome the "gap" between basic medical research and clinical application. In 1992, the scientific journal Science first presented the concept of "from bench to bedside (B2B)",(1) which was regarded as the original version of translational medicine. In 1996, Lancet first reported the new term "translational medicine". (2) With the rising of its importance in medicinal research, translational medicine also changed and enriched its definition and connotation. During the years since it was presented, it has caught the concern and attention of scholars all around the world. Many special institutes were established for conducting research on the methodology and application of translational medicine. In recent years, some centers for translational medicine have also been established in some universities and research institutions in China. The core of translational medicine is to overcome the barriers between basic medicine and clinical medicine and to build a bridge between basic medicinal researchers and doctors who are
familiar with patient's needs. Firstly, it translates the knowledge and findings of basic research into clinical practice quickly to provide a new method of diagnosis and treatment, improving the level of disease diagnosis and treatment and health care. Secondly, according to the opinions and hypothesis of clinicians, it designs basic experimental research to examine and verify the findings.(3) It is a sequential and bidirectional process from bench to bedside then from bedside to bench. Some scholars specified that translational medicine is not an isolated idea which can be applied at all times, but an idea to which attention should be paid by medicinal researchers and doctors. Translational medicine should become
© The Chinese Journal of Integrated Traditional and Western Medicine Press and Springer-Verlag Berlin Heidelberg 2014 △ These two authors contributed equally to this article Supported by the National Basic Research Program of China (973 Program, No. 2011CB505403) Center for Studies in Constitution Research of Traditional Chinese Medicine, Basic Medical School, Beijing University of Chinese Medicine, Beijing (100029), China Correspondence to: Prof. WANG Qi, Tel: 86-10-64286867, E-mail: [email protected] DOI: 10.1007/s11655-014-2019-8
•2•
the foundation of human health provision,(4) involving many big conceptions in disciplines related to human health.(5) It should be pointed out that though wide attention has been paid to translational medicine in all disciplines of modern medicine including some scholarly investigation into traditional medicine, (6) there are still few successful translational examples from bench to bedside.(7) One of the problems is that the processes of laboratory research and clinical trials are different. The subjects of laboratory research are cells and animals, while for clinical trials the subjects are human beings. There are significant differences between them. Compared with western medicine, the process of Chinese medicine research is different; reducing the distance between laboratory research and clinical practice with direct application of Chinese physician's thought on the subjects of clinical practice, patients. The advantage of this process is Chinese medicine research is in the "translational" cycle by itself, skipping laboratory research. However, the lack of laboratory research is also its disadvantage, leading to the confinement of "translation" results to the experimental phase and difficultly in exploration of its principle. Constitution of Chinese medicine is a new subject developed in the 1970s. From the beginning of constitution of Chinese medicine, clinical application was given priority. It is regarded as the fundamental point of the construction of theory system, and the theory system has been verified with modern scientific methods. Under the guidance of constitution of Chinese medicine and basic medicinal research, the Standards of Classification and determination of Constitution of Chinese Medicine was developed and the Constitution of Chinese Medicine Scale invented as tools for constitution classification. (8) It fully demonstrates the idea of translating medicinal theory into clinical practice and provides a practical pathway for the implementation of translational medicine.
Idea of Translational Medicine in Research of Constitution Theory Constitution of Chinese medicine defines the conception of constitution and proposes three key scientific problems of constitution research, namely "classification of constitution of Chinese medicine", "relationship between constitution and disease" and
Chin J Integr Med
"adjustment of constitution",(9) establishing the overall framework of constitution of Chinese medicine theory. It describes characteristics of personal constitution in morphological structure, physiological function, psychological characteristics and reactive state. Based on the four aspects of individual differences, the constitutions of Chinese people are classified into nine basic types, namely balanced constitution, qi-deficient constitution, yang-deficient constitution, Yin-deficient constitution, phlegm-dampness constitution, damp-heat constitution, stagnant blood constitution, stagnant qi constitution and inherited special constitution.(10) The classification of constitution of Chinese medicine is from a clinical perspective and based on changes and characteristics of constitution and relationship between constitutions with diseases of patients. It inherited the perspective of constitution classification in The Inner classic; referred to theories of Western scholars such as "Four body fluid" of ancient Greece and "Temperament and body shape"; and combined the methods of classification of individual differences from perspectives of the relationship between the occurrence, character, development and prognosis of disease and constitution in Treatise on Cold Damage. (11) After the construction of constitution classification theory, methods of presenting individual genetic differences such as molecular biology, genomics, metanomics and single nucleotide polymorphisms (SNPs) were used to conduct research on constitution. These have shown that there are characteristic biological bases in all the nine constitutional types.(12) Therefore, the classification of constitution of Chinese medicine comprehensively reflects the biological, physiological and psychological characteristics of human being and integrates these characteristics. Moreover, on consideration of the relationship between constitution and disease and adjustment of constitution for disease prevention, this classification can provide effective guides to the prevention and management of disease and clinical practice.
Application of Constitution Theory in Clinical Practice and Public Health as the Specific Practice of Transitional Medicine Constitution of Chinese medicine not only constructed a complete constitutional classification system, but also conducted a great deal of basic
Chin J Integr Med
medicinal research on the relationship between constitution and disease, and adjustment of constitution for preventing disease. It provides operational, practical tools for the identification of constitution of Chinese medicine in the Constitution of Chinese Medicine Scale and the Classification and determination of Constitution of Chinese Medicine. The standards were enacted as sectional standards by the China Association of Chinese Medicine in 2009. The research findings of constitution of Chinese medicine have been applied in clinical practice and public health. Nationwide application of constitution differentiation has shown good effect.
Prevention and Application of the Diagnosis and Treatment Model of Constitution-DiseaseSyndrome Differentiation An important factor affecting and restricting the improvement of therapeutic effects of Chinese medicine has been that the single clinical thinking model hinders the recognition of complex multiphenomena in clinical practice. In recent decades, attention has only been paid to treatment based on syndrome differentiation and constitution differentiation, disease differentiation was neglected and clinical thinking restricted, which hindered improvements at the clinical diagnosis and treatment level. A new concept of "treatment based on constitution" is presented by constitution of Chinese medicine.(13) Treatment based on constitution regards constitution as a subject for recognition and grasps the general elements and individual differences of constitution state as well as the characteristics of different constitutions to determine the principle for prevention and treatment and select methods for treatment, prevention or health preservation, which is an intervention of "treatment in accordance with personal state". It enriches the clinical diagnosis and treatment system, especially with regard to diagnosis and treatment for diseases related to constitution and intervention for sub-health with special advantages. For different constitution types, the bodies have different susceptibility to certain pathogenic factors or diseases, leading to people with certain constitution being susceptible to certain diseases. Since people with different constitutions react differently to pathogenic factors, there are different syndromes affecting the development and prognosis of disease.
•3•
Only when the characteristics of constitution are definite, can analysis of the diseases in patients with those constitutions be done and appropriate interventions be taken. Therefore, characteristics of constitution determine and affect the prevention and treatment of disease as well as the preservation and improvement of health. The main subject of constitution differentiation is "human". The target of syndrome differentiation is "disease", focusing on the pathological character and principle of disease in a certain phase. The target of disease differentiation is the pathological character and principle of disease in the overall process. From the perspective of the human body, constitution explains the physiological and pathological states of the body, while syndrome and disease are explained from this different perspective. Since there are different aspects of the nature of individual diseases reflected by "constitution", "syndrome" and "disease", the combination of "constitution differentiation", "syndrome differentiation" and "disease differentiation" is necessary to comprehensively recognize the nature of disease. Therefore, Prof. Wang Qi presented the diagnosis and treatment model of constitutiondisease-syndrome differentiation. This model is of great significance in diagnostics, etiology, mechanism of disease and therapeutics.(14)
Application of Constitution Differentiation in Public Health Service The core technology of classification and differentiation of health state from the perspective of constitution of Chinese medicine is the Constitution of Chinese Medicine Scale which is developed under the guidance of constitution of Chinese medicine theory and based on "nine types of constitution of Chinese medicine". The scale, as the measuring tool of classification of constitution of Chinese medicine, can measure and assess the constitution of a population or a person, standardizing operational constitution differentiation. Based on the evaluation of reliability and validity of the scale, large-scale epidemiological investigation and statistical analysis were conducted by experts to develop the Standards of Classification and Determination of Constitution of Chinese Medicine issued by the China Association of Chinese Medicine in April 9th, 2009. The "Constitution classification and determination" was also adopted into the National Standards of Public Health Service.(15) In 2010, 31
•4•
centers of "preventive treatment of disease" were established and approved by the State Administration of Traditional Chinese Medicine. So far, a total of 173 centers have been established throughout 30 provinces and cities (autonomous regions and municipalities) in China. The constitution of Chinese medicine differentiation as main method of "preventive treatment of disease" has been popularized and applied nationwide. In 2011, selected units of Chinese medicine public health service were established in 74 districts and counties nationwide (covering 70 million people) by the State Administration of Traditional Chinese Medicine. The differentiation of constitution was selected by the State Administration of Traditional Chinese Medicine as the core element in Notice on Issuing Basic Standard of Chinese Medicine Healthcare Service Platform (Trial) and Notice on Issuing Basic Standard of Chinese Medicine Specialized Healthcare-service Model (Trial). It was also selected as the core element in the Summit on Preventive Treatment of Disease and Series of Lectures on "Constitution-Organs-Disease" sponsored by the State Administration of Traditional Chinese Medicine. So far, the first and second summits and four terms of lectures have been held, which trained approximate 3000 key members on differentiation of the nine constitutions in about one hundred hospitals nationwide and those key members then trained more members throughout China. The physical examination specialized with Chinese medicine constitution differentiation was accepted by the crowd.(16) At present, constitution differentiation has been gradually integrated into the public health service system of governments at different levels. According to a survey conducted in August 2011, the provinces that integrated constitution differentiation into the basic public health service system of government are as follows: Beijing, Shanghai, Guangdong, Inner Mongolia, Ningxia, Shanxi, Gansu and Shanxi; the cities (counties) that integrated constitution differentiation into the basic public health service system of government are as follows: Hangzhou, Shijiazhuang, Qingdao, Changchun, Taiyuan, Cixi city in Zhejiang Province, Nanhai city in Guangdong province, Yancheng city in Jiangsu province and Ningyang county in Shandong province. In Qingdao alone, the constitution differentiation of Chinese medicine services cover more than 170 thousand people. The Health Bureau of Pudong New Area,
Chin J Integr Med
Shanghai announced that they would base on the original ten community selected centers of "preventive treatment of disease by Chinese medicine" to develop the first "Chinese Medicine Centers for Disease Control (CDC)" and set constitution differentiation as the main element of physical examination of the population. Beijing Dongcheng district will establish personal electronic health records on constitution differentiation in 39 selected communities.
Prospective of Implication and Application of Constitution of Chinese Medicine in Translational Medicine Translational research is partially composed of the reaction to treatment and the evaluation and prediction of prognosis. The prevention and prediction of disease in modern medicine from the aspects of heredity, nutrition, life style and immunity conducts clinomics and clinical-laboratory correlative studies on risk factors, clinical diagnosis, treatment, survival and prognosis to identify principles, explain the mechanisms of occurrence and development of disease and provide evidence-based intervention.(17) Constitution of Chinese medicine explores the disease association and tendency from perspective of constitution to evaluate and predict the risk of disease, provide intervention by Chinese medicine and reduce the risk of disease occurrence. In the process of translating from theory into practice and then from practice into theory, constitution of Chinese medicine is based on Chinese medicine theory and refers to the methodology of modern medicine to conduct evidence-based studies and verify the theory. At present, to solve the three key scientific problems of constitution of Chinese medicine, research on classification of constitution are fairly complete. From the establishment of systematic theory to the development of standards of constitution classification, from the invention of a constitution differentiation tool to application in clinical practice and public health, the process is relatively mature. Although a great number of research institutes have conducted research nationwide on the relationship between constitution and disease and adjusting constitution for the prevention of disease, including 90 clinical diseases (results of electronic search on CNKI in Sep. 2011: a total of 311 articles reported studies on constitution and disease association and 58 articles reported studies on adjusting constitution
Chin J Integr Med
•5•
for prevention of disease) with the findings indicating some disease association with certain constitutions, most applied the method of epidemiological survey without exploring the specific mechanism of the association between constitution and disease and there were few randomized controlled trials on adjusting constitution for the prevention of disease. Therefore, future researchers should better apply the ideal and methods of translational medicine into constitution of Chinese medicine, conduct more randomized controlled trials in clinical and public health service, pay attention to evidencebased practice after clinical trial, conduct research on prognosis and outcome, find the latest and best evidence on basis of analysis and systematic review on comprehensive clinical achievements, establish the clinical practice guidelines, and recommend standardized intervention by adjusting constitution for prevention and treatment of disease.
medicine. Lancet 1996;348:422. 3. Nussenblatt RB, Marincola FM, Schechter AN. Translational medicine-doing it backwards. J Transl Med 2010;8:12. 4. Sonntag KC. Implementations of translational medicine. J Transl Med 2005; 3:33. 5. Ba DN. Singing 2020 China health. Nation Med J China (Chin) 2009;89:1. 6. Su JP, Sun FF, Yin CH. Clinical research under the guidance of translational medicine idea. J Med Res (Chin) 2011;40:20-22. 7. Marincola FM. The trouble with translational medicine. J Intern Med 2011;270:123-127. 8. Wang Q, Zhu YB. Standards of Classification and determination of Constitution of Chinese Medicine. China Association of Chinese Medicine, 2009. 9. Wang Q. The three theories in constitution of Chinese medicine. J Beijing Univ Tradit Chin Med (Chin) 2008;31:653-655. 10. Wang Q. Constitution of Chinese medicine, 2008 ed. Beijing: People's Health Publishing House;2009:159-175.
Additionally, comprehensive translational medicine teams are necessary to continually translate and improve the achievements of constitution research.(18) Therefore, multi-disciplinary cooperation is needed. Research institutes, hospitals, preventive and healthcare institutions, community service providers and medical companies should form a systematic and comprehensive translational research institution to continually provide model and method on diagnosis, treatment and healthcare of Chinese medicine to meet demands on different levels. We aim to improve health by applying the theory and method of constitution of Chinese medicine.
11. Wang J, Li YS, Ni CM, Zhang HM, Li LR, Wang Q.
Acknowledgement
16. Wang Q. The application of constitution of Chinese
Cognition Research and Constitutional Classification in Chinese Medicine. Am J Chin Med 2011;39:651-660. 12. Wang Q, Wang J, Zhu YB, Ni C, Li YS, Zhang HM, et al. Identification of the nine constitutions in Chinese population. Beijing: Science Press;2011:244. 13. Wang Q. The scientific significance and application of treatment based on constitution differentiation (1). J Zhejiang Univ Tradit Chin Med (Chin) 2006;30:130-133. 14. Wang Q. The scientific significance and application of treatment based on constitution differentiation (2). J Zhejiang Univ Tradit Chin Med (Chin) 2006;30:220-224. 15. Constitution classification and determination. National Standards of Public Health Service. Beijng, 2009.
We thank Dr. Yang Guo-yan of Beijing University of Chinese Medicine for the translating work, and thank Dr. Donna Winges of California University of Chinese Medicine for the
REFERENCES Choi DW. Bench to bedside: the glutamate connection. Science 1992;258:241-243. 2.
Univ Tradit Chin Med (Chin) 2011;21(2):1-4. 17. Ren CS, Xu JC. The conception, research focus and prospect of translational medicine. Chin J Lung Dis (Chin)
revising work.
1.
medicine differentiation in public health service. J Fujian
Geraghty J. Adenomatous polyposis coli and translational
2010;3:456-462. 18. Moore DR. Reverse translation: clearing a path from bedside to bench. Nature 2008;454:274. (Received December 3, 2012) Edited by GUO Yan
•1•
TRADITIONAL MEDICINE Research on Constitution of Chinese Medicine and Implementation of Translational Medicine WANG Ji (王
济)△, WANG Ting (王 停)△, LI Ying-shuai (李英帅), ZHENG Yan-fei (郑燕飞), LI Ling-ru (李玲孺), and WANG Qi (王 琦)
ABSTRACT Translational medicine is a new concept presented in recent decades, the core of which is to build a bridge between basic medical research and clinical application. From the beginning of constitution of Chinese medicine, clinical application has been given priority. Therefore, the idea of translational medicine is fully demonstrated in the research into the three key scientific problems of "classification of constitution of Chinese medicine", "relationship between constitution and disease" and "adjustment of constitution". Under its guidance, not only was the systematic theory of constitution of Chinese medicine established, but also the Constitution of Chinese Medicine Scale and the Standards of Classification and determination of Constitution of Chinese Medicine were developed, which translates methods of classifying the nine constitutional types into guidance for prevention of disease, management of health and clinical application. The research findings of constitution of Chinese medicine have been applied in clinical practice and public health, establishing the diagnosis and treatment model of constitution-disease-syndrome differentiation. The nationwide application of constitution differentiation has shown good effect. In the future, constitution of Chinese medicine should strengthen the evidence-based research and multi-disciplinary cooperation, and establish a research team on comprehensive constitution of Chinese medicine and translational medicine, to translate the findings into clinical practice and public health more accurately and quickly. KEYWORDS constitution of Chinese medicine, translational medicine, implementation
Translational medicine, also called translational research, is a new international concept presented in the field of medicine to overcome the "gap" between basic medical research and clinical application. In 1992, the scientific journal Science first presented the concept of "from bench to bedside (B2B)",(1) which was regarded as the original version of translational medicine. In 1996, Lancet first reported the new term "translational medicine". (2) With the rising of its importance in medicinal research, translational medicine also changed and enriched its definition and connotation. During the years since it was presented, it has caught the concern and attention of scholars all around the world. Many special institutes were established for conducting research on the methodology and application of translational medicine. In recent years, some centers for translational medicine have also been established in some universities and research institutions in China. The core of translational medicine is to overcome the barriers between basic medicine and clinical medicine and to build a bridge between basic medicinal researchers and doctors who are
familiar with patient's needs. Firstly, it translates the knowledge and findings of basic research into clinical practice quickly to provide a new method of diagnosis and treatment, improving the level of disease diagnosis and treatment and health care. Secondly, according to the opinions and hypothesis of clinicians, it designs basic experimental research to examine and verify the findings.(3) It is a sequential and bidirectional process from bench to bedside then from bedside to bench. Some scholars specified that translational medicine is not an isolated idea which can be applied at all times, but an idea to which attention should be paid by medicinal researchers and doctors. Translational medicine should become
© The Chinese Journal of Integrated Traditional and Western Medicine Press and Springer-Verlag Berlin Heidelberg 2014 △ These two authors contributed equally to this article Supported by the National Basic Research Program of China (973 Program, No. 2011CB505403) Center for Studies in Constitution Research of Traditional Chinese Medicine, Basic Medical School, Beijing University of Chinese Medicine, Beijing (100029), China Correspondence to: Prof. WANG Qi, Tel: 86-10-64286867, E-mail: [email protected] DOI: 10.1007/s11655-014-2019-8
•2•
the foundation of human health provision,(4) involving many big conceptions in disciplines related to human health.(5) It should be pointed out that though wide attention has been paid to translational medicine in all disciplines of modern medicine including some scholarly investigation into traditional medicine, (6) there are still few successful translational examples from bench to bedside.(7) One of the problems is that the processes of laboratory research and clinical trials are different. The subjects of laboratory research are cells and animals, while for clinical trials the subjects are human beings. There are significant differences between them. Compared with western medicine, the process of Chinese medicine research is different; reducing the distance between laboratory research and clinical practice with direct application of Chinese physician's thought on the subjects of clinical practice, patients. The advantage of this process is Chinese medicine research is in the "translational" cycle by itself, skipping laboratory research. However, the lack of laboratory research is also its disadvantage, leading to the confinement of "translation" results to the experimental phase and difficultly in exploration of its principle. Constitution of Chinese medicine is a new subject developed in the 1970s. From the beginning of constitution of Chinese medicine, clinical application was given priority. It is regarded as the fundamental point of the construction of theory system, and the theory system has been verified with modern scientific methods. Under the guidance of constitution of Chinese medicine and basic medicinal research, the Standards of Classification and determination of Constitution of Chinese Medicine was developed and the Constitution of Chinese Medicine Scale invented as tools for constitution classification. (8) It fully demonstrates the idea of translating medicinal theory into clinical practice and provides a practical pathway for the implementation of translational medicine.
Idea of Translational Medicine in Research of Constitution Theory Constitution of Chinese medicine defines the conception of constitution and proposes three key scientific problems of constitution research, namely "classification of constitution of Chinese medicine", "relationship between constitution and disease" and
Chin J Integr Med
"adjustment of constitution",(9) establishing the overall framework of constitution of Chinese medicine theory. It describes characteristics of personal constitution in morphological structure, physiological function, psychological characteristics and reactive state. Based on the four aspects of individual differences, the constitutions of Chinese people are classified into nine basic types, namely balanced constitution, qi-deficient constitution, yang-deficient constitution, Yin-deficient constitution, phlegm-dampness constitution, damp-heat constitution, stagnant blood constitution, stagnant qi constitution and inherited special constitution.(10) The classification of constitution of Chinese medicine is from a clinical perspective and based on changes and characteristics of constitution and relationship between constitutions with diseases of patients. It inherited the perspective of constitution classification in The Inner classic; referred to theories of Western scholars such as "Four body fluid" of ancient Greece and "Temperament and body shape"; and combined the methods of classification of individual differences from perspectives of the relationship between the occurrence, character, development and prognosis of disease and constitution in Treatise on Cold Damage. (11) After the construction of constitution classification theory, methods of presenting individual genetic differences such as molecular biology, genomics, metanomics and single nucleotide polymorphisms (SNPs) were used to conduct research on constitution. These have shown that there are characteristic biological bases in all the nine constitutional types.(12) Therefore, the classification of constitution of Chinese medicine comprehensively reflects the biological, physiological and psychological characteristics of human being and integrates these characteristics. Moreover, on consideration of the relationship between constitution and disease and adjustment of constitution for disease prevention, this classification can provide effective guides to the prevention and management of disease and clinical practice.
Application of Constitution Theory in Clinical Practice and Public Health as the Specific Practice of Transitional Medicine Constitution of Chinese medicine not only constructed a complete constitutional classification system, but also conducted a great deal of basic
Chin J Integr Med
medicinal research on the relationship between constitution and disease, and adjustment of constitution for preventing disease. It provides operational, practical tools for the identification of constitution of Chinese medicine in the Constitution of Chinese Medicine Scale and the Classification and determination of Constitution of Chinese Medicine. The standards were enacted as sectional standards by the China Association of Chinese Medicine in 2009. The research findings of constitution of Chinese medicine have been applied in clinical practice and public health. Nationwide application of constitution differentiation has shown good effect.
Prevention and Application of the Diagnosis and Treatment Model of Constitution-DiseaseSyndrome Differentiation An important factor affecting and restricting the improvement of therapeutic effects of Chinese medicine has been that the single clinical thinking model hinders the recognition of complex multiphenomena in clinical practice. In recent decades, attention has only been paid to treatment based on syndrome differentiation and constitution differentiation, disease differentiation was neglected and clinical thinking restricted, which hindered improvements at the clinical diagnosis and treatment level. A new concept of "treatment based on constitution" is presented by constitution of Chinese medicine.(13) Treatment based on constitution regards constitution as a subject for recognition and grasps the general elements and individual differences of constitution state as well as the characteristics of different constitutions to determine the principle for prevention and treatment and select methods for treatment, prevention or health preservation, which is an intervention of "treatment in accordance with personal state". It enriches the clinical diagnosis and treatment system, especially with regard to diagnosis and treatment for diseases related to constitution and intervention for sub-health with special advantages. For different constitution types, the bodies have different susceptibility to certain pathogenic factors or diseases, leading to people with certain constitution being susceptible to certain diseases. Since people with different constitutions react differently to pathogenic factors, there are different syndromes affecting the development and prognosis of disease.
•3•
Only when the characteristics of constitution are definite, can analysis of the diseases in patients with those constitutions be done and appropriate interventions be taken. Therefore, characteristics of constitution determine and affect the prevention and treatment of disease as well as the preservation and improvement of health. The main subject of constitution differentiation is "human". The target of syndrome differentiation is "disease", focusing on the pathological character and principle of disease in a certain phase. The target of disease differentiation is the pathological character and principle of disease in the overall process. From the perspective of the human body, constitution explains the physiological and pathological states of the body, while syndrome and disease are explained from this different perspective. Since there are different aspects of the nature of individual diseases reflected by "constitution", "syndrome" and "disease", the combination of "constitution differentiation", "syndrome differentiation" and "disease differentiation" is necessary to comprehensively recognize the nature of disease. Therefore, Prof. Wang Qi presented the diagnosis and treatment model of constitutiondisease-syndrome differentiation. This model is of great significance in diagnostics, etiology, mechanism of disease and therapeutics.(14)
Application of Constitution Differentiation in Public Health Service The core technology of classification and differentiation of health state from the perspective of constitution of Chinese medicine is the Constitution of Chinese Medicine Scale which is developed under the guidance of constitution of Chinese medicine theory and based on "nine types of constitution of Chinese medicine". The scale, as the measuring tool of classification of constitution of Chinese medicine, can measure and assess the constitution of a population or a person, standardizing operational constitution differentiation. Based on the evaluation of reliability and validity of the scale, large-scale epidemiological investigation and statistical analysis were conducted by experts to develop the Standards of Classification and Determination of Constitution of Chinese Medicine issued by the China Association of Chinese Medicine in April 9th, 2009. The "Constitution classification and determination" was also adopted into the National Standards of Public Health Service.(15) In 2010, 31
•4•
centers of "preventive treatment of disease" were established and approved by the State Administration of Traditional Chinese Medicine. So far, a total of 173 centers have been established throughout 30 provinces and cities (autonomous regions and municipalities) in China. The constitution of Chinese medicine differentiation as main method of "preventive treatment of disease" has been popularized and applied nationwide. In 2011, selected units of Chinese medicine public health service were established in 74 districts and counties nationwide (covering 70 million people) by the State Administration of Traditional Chinese Medicine. The differentiation of constitution was selected by the State Administration of Traditional Chinese Medicine as the core element in Notice on Issuing Basic Standard of Chinese Medicine Healthcare Service Platform (Trial) and Notice on Issuing Basic Standard of Chinese Medicine Specialized Healthcare-service Model (Trial). It was also selected as the core element in the Summit on Preventive Treatment of Disease and Series of Lectures on "Constitution-Organs-Disease" sponsored by the State Administration of Traditional Chinese Medicine. So far, the first and second summits and four terms of lectures have been held, which trained approximate 3000 key members on differentiation of the nine constitutions in about one hundred hospitals nationwide and those key members then trained more members throughout China. The physical examination specialized with Chinese medicine constitution differentiation was accepted by the crowd.(16) At present, constitution differentiation has been gradually integrated into the public health service system of governments at different levels. According to a survey conducted in August 2011, the provinces that integrated constitution differentiation into the basic public health service system of government are as follows: Beijing, Shanghai, Guangdong, Inner Mongolia, Ningxia, Shanxi, Gansu and Shanxi; the cities (counties) that integrated constitution differentiation into the basic public health service system of government are as follows: Hangzhou, Shijiazhuang, Qingdao, Changchun, Taiyuan, Cixi city in Zhejiang Province, Nanhai city in Guangdong province, Yancheng city in Jiangsu province and Ningyang county in Shandong province. In Qingdao alone, the constitution differentiation of Chinese medicine services cover more than 170 thousand people. The Health Bureau of Pudong New Area,
Chin J Integr Med
Shanghai announced that they would base on the original ten community selected centers of "preventive treatment of disease by Chinese medicine" to develop the first "Chinese Medicine Centers for Disease Control (CDC)" and set constitution differentiation as the main element of physical examination of the population. Beijing Dongcheng district will establish personal electronic health records on constitution differentiation in 39 selected communities.
Prospective of Implication and Application of Constitution of Chinese Medicine in Translational Medicine Translational research is partially composed of the reaction to treatment and the evaluation and prediction of prognosis. The prevention and prediction of disease in modern medicine from the aspects of heredity, nutrition, life style and immunity conducts clinomics and clinical-laboratory correlative studies on risk factors, clinical diagnosis, treatment, survival and prognosis to identify principles, explain the mechanisms of occurrence and development of disease and provide evidence-based intervention.(17) Constitution of Chinese medicine explores the disease association and tendency from perspective of constitution to evaluate and predict the risk of disease, provide intervention by Chinese medicine and reduce the risk of disease occurrence. In the process of translating from theory into practice and then from practice into theory, constitution of Chinese medicine is based on Chinese medicine theory and refers to the methodology of modern medicine to conduct evidence-based studies and verify the theory. At present, to solve the three key scientific problems of constitution of Chinese medicine, research on classification of constitution are fairly complete. From the establishment of systematic theory to the development of standards of constitution classification, from the invention of a constitution differentiation tool to application in clinical practice and public health, the process is relatively mature. Although a great number of research institutes have conducted research nationwide on the relationship between constitution and disease and adjusting constitution for the prevention of disease, including 90 clinical diseases (results of electronic search on CNKI in Sep. 2011: a total of 311 articles reported studies on constitution and disease association and 58 articles reported studies on adjusting constitution
Chin J Integr Med
•5•
for prevention of disease) with the findings indicating some disease association with certain constitutions, most applied the method of epidemiological survey without exploring the specific mechanism of the association between constitution and disease and there were few randomized controlled trials on adjusting constitution for the prevention of disease. Therefore, future researchers should better apply the ideal and methods of translational medicine into constitution of Chinese medicine, conduct more randomized controlled trials in clinical and public health service, pay attention to evidencebased practice after clinical trial, conduct research on prognosis and outcome, find the latest and best evidence on basis of analysis and systematic review on comprehensive clinical achievements, establish the clinical practice guidelines, and recommend standardized intervention by adjusting constitution for prevention and treatment of disease.
medicine. Lancet 1996;348:422. 3. Nussenblatt RB, Marincola FM, Schechter AN. Translational medicine-doing it backwards. J Transl Med 2010;8:12. 4. Sonntag KC. Implementations of translational medicine. J Transl Med 2005; 3:33. 5. Ba DN. Singing 2020 China health. Nation Med J China (Chin) 2009;89:1. 6. Su JP, Sun FF, Yin CH. Clinical research under the guidance of translational medicine idea. J Med Res (Chin) 2011;40:20-22. 7. Marincola FM. The trouble with translational medicine. J Intern Med 2011;270:123-127. 8. Wang Q, Zhu YB. Standards of Classification and determination of Constitution of Chinese Medicine. China Association of Chinese Medicine, 2009. 9. Wang Q. The three theories in constitution of Chinese medicine. J Beijing Univ Tradit Chin Med (Chin) 2008;31:653-655. 10. Wang Q. Constitution of Chinese medicine, 2008 ed. Beijing: People's Health Publishing House;2009:159-175.
Additionally, comprehensive translational medicine teams are necessary to continually translate and improve the achievements of constitution research.(18) Therefore, multi-disciplinary cooperation is needed. Research institutes, hospitals, preventive and healthcare institutions, community service providers and medical companies should form a systematic and comprehensive translational research institution to continually provide model and method on diagnosis, treatment and healthcare of Chinese medicine to meet demands on different levels. We aim to improve health by applying the theory and method of constitution of Chinese medicine.
11. Wang J, Li YS, Ni CM, Zhang HM, Li LR, Wang Q.
Acknowledgement
16. Wang Q. The application of constitution of Chinese
Cognition Research and Constitutional Classification in Chinese Medicine. Am J Chin Med 2011;39:651-660. 12. Wang Q, Wang J, Zhu YB, Ni C, Li YS, Zhang HM, et al. Identification of the nine constitutions in Chinese population. Beijing: Science Press;2011:244. 13. Wang Q. The scientific significance and application of treatment based on constitution differentiation (1). J Zhejiang Univ Tradit Chin Med (Chin) 2006;30:130-133. 14. Wang Q. The scientific significance and application of treatment based on constitution differentiation (2). J Zhejiang Univ Tradit Chin Med (Chin) 2006;30:220-224. 15. Constitution classification and determination. National Standards of Public Health Service. Beijng, 2009.
We thank Dr. Yang Guo-yan of Beijing University of Chinese Medicine for the translating work, and thank Dr. Donna Winges of California University of Chinese Medicine for the
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