
==== Front
Medicine (Baltimore)
Medicine (Baltimore)
MD
Medicine
0025-7974
1536-5964
Lippincott Williams & Wilkins Hagerstown, MD

MD-D-24-01565
00070
10.1097/MD.0000000000039560
3
6900
Research Article
Systematic Review and Meta-Analysis
The correlation between traditional Chinese medicine constitution and primary osteoporosis: A systematic review and meta-analysis
Qu Qi MS 542710831@qq.com
ab
Jiang Rui MS jrui388@gmail.com
bc
Luo Feng MS 2280769099@qq.com
d
Mou Shuanglin MD lingyiner@126.com
c
Zhang Zheng MD Zz18062200053@163.com
bc
https://orcid.org/0009-0006-4185-3466
Zhu Wensheng MD b*
a Department of Medicine, Hubei Minzu University, Enshi, China
b Department of Orthopedics, Huanggang Hospital of Traditional Chinese Medicine affiliated with Hubei University of Chinese Medicine, Huanggang, China
c Graduate school, Hubei University of Traditional Chinese Medicine, Wuhan, China
d Department of Rehabilitation, Huanggang Central Hospital, Huanggang, China.
* Correspondence: Wensheng Zhu, Department of Orthopedics, Huanggang Hospital of Traditional Chinese Medicine affiliated with Hubei University of Chinese Medicine, Huanggang 438000, China (e-mail: 1245749181@qq.com).
13 9 2024
13 9 2024
103 37 e3956010 2 2024
13 8 2024
14 8 2024
Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal.

Background:

In recent years, as societal awareness of the risks associated with primary osteoporosis (POP) has deepened, numerous studies have explored the relationship between POP and Traditional Chinese Medicine (TCM) constitution types. To further clarify the TCM constitution types closely associated with POP and provide evidence-based medical support for the prevention and treatment of osteoporosis from a TCM perspective, we have employed evidence-based methods to investigate the relationship between POP and TCM constitution types.

Methods:

We conducted a comprehensive search of observational studies on the relationship between POP and TCM constitutional types in databases, including PubMed, Embase, MEDLINE, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Wanfang, and Chinese Scientific Journal Database (VIP), up to October 2023.

Results:

After literature selection, data extraction, and bias assessment, 29 studies were included in the meta-analysis, comprising 20 cross-sectional studies and 9 case-control studies. Using R software (version 4.2.3), we analyzed the distribution of TCM constitutional types in POP patients and compared the TCM constitutional types between POP patients and healthy individuals. The meta-analysis results revealed that in POP patients, Yang-deficiency constitution accounted for 22.7% (95% CI: 19.8–25.8%), Yin-deficiency constitution accounted for 15.8% (95% CI: 13.0–18.6%), and Qi-deficiency constitution accounted for 14.1% (95% CI: 12.2–16.0%). The proportions of the three mentioned TCM constitutions all exceed that of the Balanced constitution, with the balanced constitution accounting for 12.3% (95% CI: 7.4–18.1%). The proportions of Yang-deficiency, Yin-deficiency, and Qi-deficiency constitutions were higher in POP patients compared to healthy individuals, with odds ratios (OR) of 2.36 (95% CI: 1.43–3.89), 1.69 (95% CI: 1.36–2.04), and 1.80 (95% CI: 1.23–2.64), respectively, while the Balanced type was lower in POP patients with an OR of 0.16 (95% CI: 0.11–0.23) compared to healthy individuals.

Conclusion:

The evidence suggests that the Yang-deficiency constitution, Yin-deficiency constitution, and Qi-deficiency constitution are the predominant TCM constitutional types in POP patients. Furthermore, Yang-deficiency constitution, Yin-deficiency constitution, and Qi-deficiency constitution may serve as potential risk factors for POP, while the Balanced constitution may act as a protective factor.

meta-analysis
primary osteoporosis
systematic review
traditional Chinese medicine constitution
Natural Science Foundation of Hubei Province 10.13039/501100003819 2024AFB976 Zheng ZhangScience and Technology Innovation Special Project of Huanggang CityYBXM20240045 Wensheng ZhuOPEN-ACCESSTRUE
SDCT
==== Body
pmc1. Introduction

Primary osteoporosis (POP) is a systemic bone disorder characterized by a reduction in bone mass and decreased skeletal strength resulting from multiple contributing factors.[1] POP is a common condition among middle-aged and elderly individuals, with critical symptoms including pain, reduced functional capacity, and, in severe cases, kyphosis, as well as an increased susceptibility to fragility fractures. The incidence of POP is positively associated with age, with a higher prevalence in older individuals.[2] According to epidemiological surveys on osteoporosis in China, the prevalence of osteoporosis in individuals aged 50 and above is 19.2%. For those aged 65 and above, the prevalence of primary osteoporosis is approximately 32.1%.[3] A recent study on vertebral fracture screening in the community population in Shanghai found that in individuals aged 60 and above, the prevalence of vertebral fractures is similar for both men and women, with a rate of 17% in men and 17.3% in women.[4] POP has a significant impact on the health of the middle-aged and elderly population, imposing a substantial burden on individuals, families, and society.

Chinese Constitution Medicine (CCM) is a discipline that, guided by the principles of traditional Chinese medicine (TCM), studies the constitutional characteristics and types of individuals while also analyzing the nature and progression of diseases. Its primary objective is to facilitate disease prevention, treatment, and the promotion of health and rehabilitation.[5,6] In TCM theory, the TCM constitution is believed to be formed through the combined influence of innate and acquired factors, and it can affect an individual’s susceptibility to diseases. Wang Qi’s Nine-Body Constitution Classification in TCM categorizes TCM constitution into nine types: Balanced constitution, Qi-deficiency constitution, Yang-deficiency constitution, Yin-deficiency constitution, Phlegm damp constitution, Damp heat constitution, Blood stasis constitution, Qi stagnation constitution, and Special diathesis constitution.[7] The last eight types are considered imbalanced TCM constitutions. For detailed information, please refer to Supplementary File 1, Supplemental Digital Content, http://links.lww.com/MD/N519.

Over six years, Lu et al[8] conducted a statistical analysis of 10,381 individuals aged 14 and above, focusing on common chronic diseases and TCM constitutional types. They discovered that within the population of individuals with chronic illnesses, aside from the Balanced constitution, various imbalanced constitutional types exhibited different tendencies. For example, patients with cardiovascular and pulmonary conditions, such as bronchial asthma, hypertension, and coronary heart disease, predominantly displayed a Qi-deficiency constitution. Those with digestive ulcers, diabetes, and osteoporosis primarily exhibited a Yang-deficiency constitution. Obesity and hyperlipidemia patients were mainly associated with a Phlegm-damp constitution, while individuals with tumors had Qi-deficiency and Yang-deficiency constitutions as the predominant features.[8] This suggests that different types of diseases are associated with distinct TCM constitutional tendencies.

While TCM constitutions are relatively stable, they are not entirely fixed. Therefore, by intervening and adjusting one’s TCM constitution, it is possible to prevent the onset of diseases and alter the course of disease progression.[9] By modifying daily routines, dietary habits, exercise, and other lifestyle factors, individuals with imbalanced TCM constitutions can transition towards a more balanced TCM constitution, reducing the likelihood of disease occurrence.[10] Given the pivotal role of traditional Chinese constitutions in the occurrence, development, and progression of diseases, the study of susceptibility constitution types in POP holds significant clinical importance for achieving personalized diagnosis and treatment and population-level prevention.[6,11] Recently, numerous clinical studies nationwide have explored the association between Chinese constitutional types and POP patients. However, the individual sample sizes in these studies have been relatively limited, and case distributions have been somewhat scattered.

Therefore, through systematic evaluation and meta-analysis, this research aims to increase the sample size of studies related to the correlation between POP and Chinese constitutional types, thereby enhancing the representativeness of such research. Simultaneously, This study aims to obtain more reliable evidence-based results by conducting rigorous statistical analyses and minimizing biases. It seeks to examine the distribution of Chinese constitutional types in patients with POP, identify TCM constitutional types linked to POP susceptibility, and ultimately offer a higher level of evidence-based medicine for the clinical prevention and treatment of POP.

2. Methods

This systematic review and meta-analysis strictly adhered to the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).[12] The research procedures were carried out following a predefined protocol and registered with the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42023465979.

2.1. Search strategy

Comprehensive literature searches were conducted in the following databases: PubMed, Embase, MEDLINE, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Wanfang, and Chinese Scientific Journal Database (VIP). No restriction was set on the publication date. The database searches were limited to journal articles written in the English and Chinese languages only. No language, nationality, or publication restrictions were applied. The search covered databases up to October 2023.The search terms used are presented in Supplementary Table S1, Supplemental Digital Content, http://links.lww.com/MD/N521. Additionally, the references of the included studies were manually searched to identify other relevant studies.

2.2. Inclusion criteria

The inclusion criteria were: (1) Study Type: An observational study was conducted to investigate the association between Traditional Chinese Medicine (TCM) constitutions and osteoporosis, comprising cross-sectional research and case-control studies.(2) Study Population: The case group consisted of subjects definitively diagnosed with osteoporosis according to widely accepted public criteria. In the presence of a control group, it should consist of healthy individuals.

(3) Constitution Measurement: TCM constitutions were identified using the TCM Constitution Classification Criteria recommended by the Chinese Medical Association in 2009 (CCMQ).[13] The study should include the distribution data of the nine basic constitution types.(4) Results: The study should report the distribution of TCM constitutions among patients with osteoporosis and/or non-osteoporotic individuals. The Constitution in Chinese Medicine Questionnaire (CCMQ) is shown in Supplementary File 2, Supplemental Digital Content, http://links.lww.com/MD/N519.

2.3. Exclusion criteria

The exclusion criteria were: (1) Literature lacking basic participant information or without statistics on constitutional components. (2) Literature involving subjects suffering from other severe conditions that significantly impact physical fitness. (3) Literature focusing on patients with secondary osteoporosis. (4) Repetitive literature based on data from the same study population. (5) Literature where there is overlap in data from the same institution; preference should be given to literature with larger sample sizes. (6) Literature with apparent data errors or non-uniform constitutions.

2.4. Data extraction

According to the established and comprehensive inclusion and exclusion criteria, initial screening of the literature was conducted independently by two researchers. The process began with a review of the literature titles and abstracts, followed by a thorough examination of the full text. Ineligible literature was removed, while literature meeting the criteria was included in the study. Finally, the two researchers cross-checked each other’s selected literature to ensure compliance with the criteria. If one of the researchers had concerns about a particular piece of literature, a discussion was held to determine whether it should be included in the study. In cases where a consensus could not be reached, a third-party system researcher made the final evaluation and decision regarding inclusion.

2.5. Quality assessment

The evaluation of cross-sectional studies utilized the assessment tool endorsed by the Agency for Healthcare Research and Quality (AHRQ).[14] This tool encompasses 11 elements, with the highest achievable score being 11, where a range of 0 to 3 signifies low quality, 4 to 7 indicates moderate quality, and 8 to 11 denotes high quality. As for the assessment of case-control and cohort studies, the Newcastle-Ottawa Scale (NOS)[15] was employed, which takes into account the selection of the study population, comparability, exposure, and outcome, yielding a maximum score of 9. Two independent investigators conducted the quality assessment. In instances of disagreement, a third investigator was consulted for resolution.

2.6. Data analyses

The Meta-analysis of single-group rates for each constitution type was conducted using R Software version 4.2.3. The analytical model was selected based on the results of the heterogeneity test. Percentages and their corresponding 95% confidence intervals (95% CI) were calculated for the Balanced constitution and the other eight imbalanced constitution types within the POP population. In cases of significant heterogeneity, subgroup analyses were conducted based on age, gender, and geographical factors. For the case-control study analysis, R Software version 4.2.3 was employed to analyze data from the POP group in comparison to the healthy control group. In cases of statistical heterogeneity (P < .05 or I2 > 50%), a random-effects model was employed; otherwise, a fixed-effects model was chosen.[16] Additionally, publication bias was evaluated utilizing funnel plots.

3. Result

3.1. Study characteristics and Quality assessment results

A total of 517 studies were included during the database search. Then, 187 duplicate studies were removed using the Endnote software. After reading the titles and abstracts, 51 articles were included. After retrieving and screening the full texts of the remaining studies, 29 eligible studies[11,17–44] with 8771 participants were finally included. Figure 1 shows the specific screening process and results. All 20 cross-sectional and 9 case-control studies were Chinese articles. The major characteristics of the included studies are summarized in Table S2, Supplemental Digital Content, http://links.lww.com/MD/N521. The quality assessment results according to the NOS and AHRQ of included studies are listed in Table S3 and S4, Supplemental Digital Content, http://links.lww.com/MD/N521. Overall, the scores ranged from 5 to 8.

Figure 1. PRISMA flowchart.

3.2. The results of Meta-analysis

3.2.1. Meta-analysis of the distribution of TCM constitutions

In a total of 29 research reports on the distribution of TCM constitutions in patients with POP, there were a combined 8771 POP patients included. Sample sizes ranged from a minimum of 30 cases to a maximum of 1000 cases. The results of the meta-analysis revealed that among POP patients, the distribution of eight specific constitutional types was predominantly characterized by Yang-deficiency constitution (22.7%), Yin-deficiency constitution (15.8%), and Qi-deficiency constitution (14.1%), all of which had the highest proportional representation. Notably, these proportions exceeded that of the Balanced constitution (12.3%). Among the constitutional types with a proportion lower than the Balanced constitution, the Blood stasis constitution accounted for 9.6%. In comparison, the other four constitutional types each represented less than 6% of the total cases.

3.2.1.1. (1) Proportion of Yang-deficiency constitution

Due to significant heterogeneity among the included studies (I² = 91.52%, P < .01), a random-effects model was employed. The results indicate that the proportion of Yin-deficiency Constitution among POP patients is 22.7% (95% CI: 19.8–25.8%). Please refer to Figure 2 for the forest plot representation.

Figure 2. Forest plot of studies on association between Yang-deficiency constitution and POP.

3.2.1.2. (2) Proportion of Yin-deficiency constitution

Considerable heterogeneity was detected for studies with the Yin-deficiency constitution (I2 = 93.56%, P < .01). Hence, a random-effects model was used. The meta-analysis revealed that the proportion of Yin-deficiency constitution was 15.8% (95% CI: 13.0–18.6%). The forest plot is shown in Figure 3.

Figure 3. Forest plot of studies on association between Yin-deficiency constitution and POP.

3.2.1.3. (3) Proportion of Qi-deficiency constitution

A random-effects model was used for the Qi-deficiency constitution due to the high heterogeneity (I2 = 86.13%, P < .01). The proportion of Qi-deficiency constitution was 14.1% (95% CI: 12.2–16.0%). The forest plot is shown in Figure 4.

Figure 4. Forest plot of studies on association between Qi-deficiency constitution and POP.

3.2.1.4. (4) Proportions of other TCM constitutions

Apart from the three types of TCM constitutions, the proportion of Balanced constitution in POP patients is 12.3%. In contrast the proportions of the remaining five TCM constitutions are relatively low, and all proportions are lower than that of the Balanced constitution. The proportion of Blood stasis constitution in POP patients is 9.6%, and the proportions of the others are all below 6%. The proportions of the remaining six traditional Chinese medicine constitutions in POP patients, from high to low, are as follows: Balanced constitution, Blood stasis constitution, Qi stagnation constitution, Phlegm dampness constitution, Damp heat constitution, and Special constitution. Statistical results show significant heterogeneity, with I2 values for all constitution types exceeding 50%. Therefore, a random effects model was used for analysis. Specific data can be found in Table S5, Supplemental Digital Content, http://links.lww.com/MD/N521.

3.2.2. Subgroup analyses

Due to the high heterogeneity in the combined studies and the susceptibility of TCM constitutions to various factors such as gender, age, region, dietary habits, lifestyle, and more, we conducted subgroup analyses based on gender, age, and region for the common TCM constitutions(Yang-deficiency constitution, Yin-deficiency constitution and Qi-deficiency constitution), taking into account the data included in the studies.

3.2.2.1. (1) Gender

A total of 14 studies were included, comprising 3529 female patients with POP. A meta-analysis was conducted to examine the distribution of three common TCM constitutions in female POP patients. Due to substantial heterogeneity, a random-effects model was employed. Among female POP patients, the proportion of Yang-deficiency constitution was 24.0% (95% CI: 18.9–29.1%), showing significant heterogeneity (I2 = 91.56%, P < .01). The proportion of Yin-deficiency constitution was 14.2% (95% CI: 10.1–18.3%), also exhibiting substantial heterogeneity (I2 = 93.57%, P < .01). Additionally, the proportion of Qi-deficiency constitution was 14.2% (95% CI: 11.4–17.1%), and it showed considerable heterogeneity as well (I2 = 80.64%, P < .01). The meta-analysis forest plots for the Yang-deficiency constitution, Yin-deficiency constitution, and Qi-deficiency constitution can be found in Figures 5, 6, and 7, respectively.

Figure 5. Forest plot of studies on the association between Yang-deficiency constitution and female POP patients.

Figure 6. Forest plot of studies on the association between Yin-deficiency constitution and female POP patients.

Figure 7. Forest plot of studies on the association between Qi-deficiency constitution and female POP patients.

3.2.2.2. (2) Age

A total of 5 studies reported on the distribution of TCM constitutions in POP patients aged 45 to 55, while 3 studies reported on those aged 55 to 65, and 3 studies reported on those over 65. The meta-analysis revealed that among the POP patient population, those in the 45 to 55 age group had the highest prevalence of Yang-deficiency constitution, the 55 to 65 age group had the highest prevalence of Qi-deficiency constitution, and the age group over 65 had the highest prevalence of Yang-deficiency constitution. Specific data can be found in Table S6, Supplemental Digital Content, http://links.lww.com/MD/N521.

3.2.2.3. (3) Region

All the studies included in the analysis were conducted in China. Out of the 29 included articles, 10 were from the East China region, 6 from the South China region, and 5 from the North China region. These three regions had a relatively larger number of studies. There were fewer studies from other regions, with 3 from the Northeast, 3 from the Northwest, and 2 from the Central China region. Therefore, the following analysis reports the distribution of Yang-deficiency, Yin-deficiency, and Qi-deficiency constitutions among POP patients in the East China, South China, and North China regions. The meta-analysis shows that among the POP patient population in these regions, the Yang Deficiency Constitution had the highest prevalence. Specific statistical data can be found in Table S7, Supplemental Digital Content, http://links.lww.com/MD/N521.

3.2.3. Analysis of POP group vs. healthy control group

The individual rate meta-analysis has already identified that the most common imbalanced constitutions in POP patients are the Yang-deficiency constitution, Yin-deficiency constitution, and Qi-deficiency constitution, and their proportions are all higher than that of the balanced constitution. Therefore, a further comparative analysis was conducted between individuals with these common constitutions and healthy control populations.

3.2.3.1. (1) The relationship between the Yang-deficiency constitution and POP

A total of 9 case–control studies were included, comprising 4310 participants, with 2146 individuals in the case group and 2164 in the healthy control group. The meta-analysis results are as follows: The proportion of Yang-deficiency constitution in POP patients is significantly higher than that in the healthy control group, with an odds ratio (OR) of 2.36 (95% CI: 1.43–3.89). There is significant heterogeneity (I2 = 73%), and sensitivity analysis, removing studies one by one, still shows relatively high heterogeneity. However, all statistical results are meaningful, indicating result stability. Therefore, all studies were included for analysis using a random-effects model, and the results are statistically significant. Please refer to Figure 8 for the forest plot.

Figure 8. Forest plot of Yang-deficiency constitution comparison between POP patients and healthy people.

3.2.3.2. (2) The relationship between Yin-deficiency constitution and POP

A total of 9 case–control studies were included, comprising 4310 participants, with 2146 individuals in the case group and 2164 in the healthy control group. The meta-analysis results for the relationship between Yin-deficiency constitution and POP are as follows: the proportion of Yang-deficiency constitution in POP patients is significantly higher than that in the healthy control group, with an OR of 1.69 (95% CI: 1.24–2.30). There is significant heterogeneity (I2 = 62%). In sensitivity analysis, by removing studies one by one, it was found that removing the study by Cao reduced the heterogeneity (I2 = 45%). This suggests that the study by Cao was the primary source of heterogeneity. Therefore, this study was not included in the statistical analysis. A fixed-effects model was used, and the combined effect size (OR) was 1.66, with a 95% confidence interval of [1.36, 2.04]. The results are statistically significant. Please refer to Figure 9 for the forest plot.

Figure 9. Forest plot of Yin-deficiency constitution comparison between POP patients and healthy people.

3.2.3.3. (3) The relationship between Qi-deficiency constitution and POP

A total of 9 case–control studies were included, comprising 4310 participants, with 2146 individuals in the case group and 2164 in the healthy control group. The meta-analysis results for the relationship between Qi-deficiency constitution and POP are as follows: The proportion of Yang-deficiency constitution in POP patients is significantly higher than that in the healthy control group, with an OR of 1.80 (95% CI: 1.23–2.64). There is significant heterogeneity (I2 = 76%). In sensitivity analysis, by removing studies one by one, it was found that despite the persistently high heterogeneity, all statistical results remained meaningful, indicating result stability. Therefore, all studies were included for analysis using a random-effects model, and the results are statistically significant. Please refer to Figure 10 for the forest plot.

Figure 10. Forest plot of Qi-deficiency constitution comparison between POP patients and healthy people.

3.2.3.4. (4) The relationship between Balanced constitution and POP

A total of 9 case–control studies were included, comprising 4310 participants, with 2146 individuals in the case group and 2164 in the healthy control group. The meta-analysis results for the relationship between Balanced constitution and POP are as follows: The proportion of Yang-deficiency constitution in POP patients is significantly higher than that in the healthy control group, with an OR of 0.16 (95% CI: 0.11–0.23). There is significant heterogeneity (I2 = 61%). In sensitivity analysis, by removing studies one by one, it was found that removing the study by Sun reduced the heterogeneity (I2 = 20%). This indicates that the study by Sun was the primary source of heterogeneity. Therefore, this study was not included in the statistical analysis. A fixed-effects model was used, and the combined effect size (OR) was 0.19, with a 95% confidence interval of [0.15, 0.24]. The results are statistically significant. Please refer to Figure 11 for the forest plot.

Figure 11. Forest plot of Balanced constitution comparison between POP patients and healthy people.

3.3. Publication bias

To assess publication bias in studies involving nine constitutional types, we created contour-enhanced funnel plots with distinct areas represented in white, dark gray, medium gray, and light gray, indicating P > .1, 0.1 > P > .05, 0.05 > P > .01, and P < .01, respectively. The funnel plots reveal that studies on the Yang-deficiency constitution, Balanced constitution, Qi stagnation constitution, Blood stasis constitution, and Damp heat constitution exhibit relatively symmetrical distributions. In contrast, studies on other constitutional types show asymmetrical distributions, suggesting a potential publication bias, as depicted in Figure 12. Egger test further indicates a risk of bias in studies of Yin-deficiency constitution (P = .0600), Qi-deficiency constitution (P = .0077), Phlegm dampness constitution (P = .0010), and Special constitution (P = .0191), with the exception of Yang-deficiency constitution (P = .5811), Balanced constitution (P = .2802), Qi stagnation constitution (P = .2561), Blood stasis constitution (P = .8581), and Damp heat constitution (P = .2466).

Figure 12. Funnel plot analysis of the distribution of biased constitution.

4. Discussion

This study encompassed a total of 29 research studies, comprising 9 case–control studies and 20 cross-sectional investigations. The results of our comprehensive analysis revealed that among patients suffering from POP, the distribution of eight imbalanced TCM constitutional types was predominantly characterized by Yang-deficiency constitution (23.0%), Yin-deficiency constitution (15.8%), and Qi-deficiency constitution (14.2%), all of which exhibited higher prevalence compared to Balanced constitution (12.3%). Despite minor variations in the proportions of TCM constitution among POP populations across different regions, age groups, and genders, the fundamental consistency in distribution characteristics, with Yang-deficiency constitution, Yin-deficiency constitution, and Qi-deficiency constitution predominating, underscores the stability of our findings.

Furthermore, by further delving into 9 case–control studies involving a combined total of 4310 participants (2146 in the experimental group and 2164 in the control group), the meta-analysis revealed that among patients with POP, the prevalence of Yang-deficiency constitution, Yin-deficiency constitution, and Qi-deficiency constitution was 2.36 times (95% CI: 1.42, 3.89), 1.69 times (95% CI: 1.24, 2.30), and 1.80 times (95% CI: 1.23, 2.64) higher than that of the healthy population, respectively. In contrast, individuals with the Balanced constitution exhibited a significantly lower risk, with only 0.16 times (95% CI: 0.11, 0.23) compared to the general population. In light of these findings, our study suggests that the Yang-deficiency constitution, Yin-deficiency constitution, and Qi-deficiency constitution may serve as potential risk factors for POP. In contrast, the Balanced constitution may function as a protective factor. These insights provide valuable clues regarding the relationship between TCM constitution and POP, facilitating a better understanding of the risk factors associated with this disease and informing the development of preventive and intervention strategies.

TCM constitution refers to an individual’s composite and relatively stable inherent traits in terms of morphological structure, physiological functions, and psychological states that have developed during their life.[6] These traits are formed under the influence of both genetic factors and postnatal environmental conditions. They represent distinctive characteristics of an individual’s body that have adapted to the natural and societal environments.[9] These traits may be associated with the biological and metabolic processes relevant to bone health.[11,42] Our study suggests that TCM constitution may play a role in the pathogenesis of POP. Although the results of this study are observational and cannot establish causation, they provide a direction for future research. Further investigations will be instrumental in unveiling the biological mechanisms underlying the relationship between TCM constitution and POP.

In clinical practice, the discovery of this association offers valuable insights for personalized treatment and prevention. Healthcare professionals can utilize the identification of TCM constitution in POP patients to make adjustments for individuals with imbalanced constitutions. This, in turn, allows for the development of personalized intervention plans aimed at effectively managing and treating POP. Furthermore, it is advisable to prioritize individuals with the Yang-deficiency constitution, Yin-deficiency constitution, and Qi-deficiency constitution among the middle-aged and elderly population for POP prevention. Simultaneously, various osteoporosis risk assessment tools, such as the One-Minute Osteoporosis Risk Test[45] and the Osteoporosis Self-Assessment Tool,[46] can identify high-risk individuals. For those identified as high-risk, health education, lifestyle modifications, dietary adjustments, or traditional Chinese medicine interventions can be implemented to correct imbalanced constitutions, shifting them towards a Balanced constitution. This approach aims to prevent or reduce the occurrence of POP.

This study is subject to several limitations. Firstly, the quality of the original studies included in this meta-analysis was rated as moderate. Secondly, all the original studies were published in Chinese, and none of the English-language articles identified met the inclusion criteria, introducing potential selection bias. Thirdly, it is essential to note that this meta-analysis is retrospective in design and, as such, cannot establish causation. Therefore, it is vulnerable to any methodological deficiencies in the underlying studies. Lastly, not all studies explicitly outlined calculating methods for determining the TCM constitution. While the Constitution in Chinese Medicine Questionnaire (CCMQ) is a widely accepted standard measurement, variations in study methodologies could introduce biases into the research findings.

5. Conclusion

Our study findings indicate that within the POP population, the primary TCM constitution consists of the Yang-deficiency constitution, Yin-deficiency constitution, and Qi-deficiency constitution. Although there are slight variations in the distribution of TCM constitution among POP individuals of different regions, ages, and genders, the overall distribution characteristics remain fundamentally consistent. Our findings suggest that the Yang-deficiency constitution, Yin-deficiency constitution, and Qi-deficiency constitution may serve as potential risk factors for POP. In contrast, the Balanced constitution may offer a degree of protection against the condition. Therefore, the measurement of the TCM constitution holds significant relevance for the identification and prevention of POP. We recommend extending the TCM constitution assessment to the POP population. In the future, more high-quality observational studies will be necessary to provide a more scientifically grounded evidence base for the application of personalized diagnosis and treatment based on TCM constitution in the prevention and management of POP.

Author contributions

Conceptualization: Qi Qu, Wensheng Zhu.

Data curation: Qi Qu, Rui Jiang.

Formal analysis: Rui Jiang.

Funding acquisition: Zheng Zhang.

Investigation: Feng Luo.

Methodology: Feng Luo, Shuanglin Mou.

Supervision: Rui Jiang.

Visualization: Wensheng Zhu.

Writing – original draft: Qi Qu, Rui Jiang.

Writing – review & editing: Qi Qu, Rui Jiang.

Supplementary Material

Abbreviations:

95% CI 95% confidence intervals

AHRQ Healthcare Research and Quality

CNKI Chinese National Knowledge Infrastructure

NOS Newcastle-Ottawa Scale

OR odds ratios

POP primary osteoporosis

TCM Traditional Chinese Medicine

VIP Chinese Scientific Journal Database

This study was supported by the Science and Technology Innovation Special Project of Huanggang City (YBXM20240045) and Natural Science Foundation of Hubei Province (2024AFB976).

The authors declare no conflict of interest to disclose.

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Supplemental Digital Content is available for this article.

How to cite this article: Qu Q, Jiang R, Luo F, Mou S, Zhang Z, Zhu W. The correlation between traditional Chinese medicine constitution and primary osteoporosis: A systematic review and meta-analysis. Medicine 2024;103:37(e39560).

QQ, RJ, and FL contributed equally to this work.
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