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● Review
Need of integrated dietary therapy for persons
with diabetes mellitus and “unhealthy” body
constitution presentations
Yee Chi Peggy Wong
Dietetic Department, Tuen Mun Hospital, Hong Kong, China

ABSTRACT
From a perspective of Chinese medicine (CM), persons with unregulated “unhealthy” body constitution
(BC) will further develop chronic diseases, such as diabetes mellitus (DM). Conventional dietary therapy
with nutrition component has its limitations in the regulation of “unhealthy” BC. However, empirical
evidence supports that “unhealthy” BC can be regulated with food natures and flavors from a perspective
of CM. Presentations of “unhealthy” BC types, such as Yin-deficiency, Yang-deficiency and Yin-Yang-
deficiency were found in persons with DM. It would be necessary to regulate the “unhealthy” BC
presentations with integration of conventional dietary therapy and Chinese food therapy. The ultimate
goal is to either stabilize glycaemic control or prevent the development of other chronic diseases
leading to reduction of disease burden, such as disease-related poor quality of life, stress of healthcare
professionals and the rising of healthcare cost.
Keywords: body constitution; diabetes mellitus; Yin deficiency; Yang deficiency; dietary therapy
Citation: Wong YCP. Need of integrated dietary therapy for persons with diabetes mellitus and “unhealthy”
body constitution presentations. J Integr Med. 2016; 14(4): 255–268.

1 Introduction effective if both dietary approaches can be integrated in

Diabetes mellitus (DM) prevalence has been increasing
worldwide in both developed and developing countries.
In the year of 2000, the number of persons with DM
was 171 million. By the year of 2030, it will increase to
366 million with an increasing rate of about 100% in the
whole world [1]. Dietary intervention has been playing
an important role in treating DM. Empirical evidence
suggests that an integration of conventional and Chinese
dietary therapy is the best option for treating persons
with DM[2]. It is because conventional dietary therapy
targets on glycemic control, while Chinese dietary therapy
has its effectiveness in regulation of “unhealthy” body
constitution (BC). It would be more therapeutically
the management of DM so that either blood glucose level
can be stabilized for preventing diabetic complications
or “unhealthy” BC be regulated for preventing further
development of other chronic diseases. Conventional
dietary therapy in DM management generally follows the
Western approach, with nutrition component as the main
therapeutic element. In a DM dietary program or dietary
counselling, a dietician assesses the persons with DM
for blood glucose levels, body mass index, blood lipid
profiles, blood pressure and current diet intake. Persons
with DM are advised to have a balanced diet every day
including carbohydrates (50%–55% of total energy from
varieties of cereals), fat (less than 30% of total energy
from animal fat and cooking oil), protein (15%–17%

http://dx.doi.org/10.1016/S2095-4964(16)60255-8
Received January 10, 2016; accepted April 8, 2016.
Correspondence: Yee Chi Peggy Wong, DHSc; E-mail: wongp@ha.org.hk

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of total energy from varieties of meats including beef, pork,
chicken, fish, eggs, soybean products and dairy products), high
dietary fibre (at least two bowls of cooked and/or raw vegetables
and two to three pieces of fruits), low sodium (minimum food
with high salt content) and low simple sugar (minimum food
or drink with high sugar content)[3]. In contrast, assessment
and regulation of “unhealthy” BC presentations with food
natures and flavors are the key elements in Chinese dietary
therapy. Following is the review of BC and conventional
dietary therapy in DM with an implication of integrating
Chinese food therapy in current dietary practices. The review
will cover (1) BC in Chinese medicine (CM), (2) “unhealthy”
BC presentations in DM, (3) conventional dietary therapy,
and (4) Chinese food therapy.
2 BC in CM
From a perspective of CM, BC represents the health
status of a population or an individual in terms of physical
structure, physiological function, pathological reaction,
psychological or mental stability and metabolism[4–6]. It
is classified into “healthy” BC, “sub-healthy” BC and
“unhealthy” BC[7].
2.1 “Healthy” BC
The World Health Organization defines health as “a
state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity”[8].
CM takes the concept of “health” to be a balance of
Yin (cold) and Yang (hot) as the main criterion that
makes one “healthy”[6]. The Yellow Empero’s Canon of
Internal Medicine, which is the first Chinese medical
text, records: “Those who knew the way of keeping up
good health always followed the principle of Yin and
Yang.”[9] “Good health” in CM is described to be “Yin
and Yang in equilibrium is the best life”[10]. “Best life” is
compatible with the outcome as stated in the definition
of health by the World Health Organization [8]. From
a perspective of CM in human health, Yin is the vital
essence inside the body corresponds to blood, body fluid
(sweat, tear, saliva, and drool), nutrients [11], and other
vital substances, such as the hormones, enzymes, trace
chemical elements and neurotransmitters[12] while Yang
corresponds to vital energy utilizing the vital essence[11].
A balance of Yin and Yang implies that Yang acts on Yin
or Yin supports Yang while achieving outcomes[11]. Light
is emitted when an oil lamp is filled with oil (Yin) and
ignited with a spot of fire (Yang). A healthy BC requires
that the Yin of one’s body can be utilized by Yang that, in
turn, generates the continuing production of body Yin[11].
Yin and Yang works closely together to make the bodily
system function properly, resulting in a balance state of
physiological and psychological levels. With such a Yin
and Yang equilibrium, the body is able to resist and adapt
July 2016, Vol 14, No.4 256
to internal and external stimulations[7]. Thus, disease can
be prevented.
2.2 “Sub-healthy” BC
“Sub-health” is a term being used in China to describe
health status in-between “healthy” and “unhealthy”
stages[12,13,14]. In contrast to “health”, “sub-health” in CM
is described to be “Yin and Yang not in equilibrium”[9].
It is because “sub-healthy” BC reflects the person’s
body temperature and humidity state with “cold”,
“heat”, “dryness” and “wetness or dampness” natures of
presentations, such as “heat-dampness”, “cold-dampness”,
“heat-dryness” or “cold-dryness”. From a perspective of
CM, the “heat” and “dryness” are of Yang nature while
the “cold” and “dampness” of Yin nature[15]. Persons with
“sub-health” have clinical complaints, such as insomnia,
malaise and overweight [7]. Insomnia and overweight
are common complaints encountered by dieticians at
dietary counselling in clinical setting. Without immediate
appropriate treatment to regulate the inner “cold-heat” and
“dampness-dryness”, this person will enter a disease state
with “pathological” BC[7]. However, persons with “sub-
healthy” BC are also found in the healthy population.
One survey reported that 14.8%–31.9% of the healthy
population had “heat-dryness” type of BC[16]. Common
complaints that are encountered by persons with “sub-
health” are depressed mood, irritability, anxiety, fatigue
and muscle pain, but these unhealthy body conditions
are usually not considered serious problems in Western
medicine due to lacking of clinical evidence [17,18]. CM
argues that such clinical complaints are some kinds of
adverse reactions towards a failure of keeping the body
conditions in a homeostatic state[7]. For example, a stable
core temperature in human body is around 36.5–37.5 ºC
which maintains the harmony of the body biochemical
and psychological regulatory mechanisms. In CM, “cold”
and “hot” response to changes in body temperature.
But if they fail to maintain a balance state for what
reasons, the internal buffering system will be affected,
causing a raising core temperature. Such a disordered
body temperature will lead to heat-associated signs and
symptoms such as muscle weakness, headache, dizziness,
sleepiness, fatigue and even confusion[19]. Sleepiness is
the most common problem reported by patients at dietary
counselling. “Sub-health” occurs in a healthy person who
is suffering from these discomforts. However, this person
is no longer said to be healthy but having “unhealthy” BC
in a “sub-healthy” status from the perspective of CM.
2.3 “Unhealthy” BC
As discussed earlier in this section, “unhealthy” BC
is developed in persons with “sub-health” if untreated
properly. Persons with Yang-deficiency which is
a “cold-dampness” type of BC lacking of “heat”
present with subnormal temperature and/or body fluid
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retention [20], resulting in a disturbance of endocrine 3 “Unhealthy” BC presentations in DM

functioning[21]. Yang-deficiency is at risk of cancer[22].
Yin-deficiency is characterized by loss of body fluid
leading to excess “heat” [23] which causes cell and
tissue damage due to inflammation[7]. Hypertension is
a typical disease in this “heat-dryness” type of BC [24].
Subnormal body temperature and humidity give rise
to the occurrence of “blood-stasis” with clinical signs
and symptoms such as feeling of numbness over the
body, poor circulation, cold limbs and purple lips [23].
A feeling of numbness is commonly reported by
persons with DM at dietary counselling. Persons with
“phlegm-dampness” due to high temperature with high
humidity have clinical complaints, such as edema,
fatigue and poor digestive function[25]. Cold feeling and
poor digestive function are also common complaints
encountered by dieticians at dietary counselling.
Without appropriate regulation of these “unhealthy”
BCs, health risks might be induced. From a perspective
of CM, Yin-deficiency is the basis of DM[26] due to the
depletion of the person’s insulin, which is a hormone
according to Western medicine [1]. Hormone is of Yin
nature from a perspective of CM[11]. By integration of
the theories in Western medicine and CM, a depletion
of insulin leads to a Yin-deficiency type of BC,
potentially causing DM. Besides, Yang-deficiency and
Yin-Yang-deficiency are also commonly recognized
“unhealthy” BC types in DM population[26–30].
From a perspective of CM, “unhealthy” BC
presentations represent the signs and symptoms at certain
disease states[31]. CM scholars have their respective view
points on the presentations of Yin-deficiency and Yang-
deficiency types of BC in DM based on their clinical
experiences.
3.1 Yin-deficiency presentation
Eighteen presentations of Yin-deficiency type of BC
were observed from six references[14,27,32–35]. Five references
(Table 1) highly recognize “constipation” followed by
“feeling hot with the body and/or hands”, “mouth, lip and/
or throat are very dry” and “tinnitus” in four references,
and “thirsty with adequate water and tea” in three
references. “Constipation” is a common presentation in
persons with DM and Yin-deficiency type of BC. It is said
in the Synopsis of Prescriptions of the Golden Chamber:
“The consequent interaction of constipation and frequent
urination brings on polydipsia.” [36] This is a valuable
record by Zhang Zhongjing (a great doctor of CM in the
3rd century AD) that a person with DM has a tendency
of suffering from constipation. As reported by Xiong and
Zhu[37] regarding a study on 104 cases of type 2 diabetes
mellitus (T2DM), 50.6% had constipation. In an article,
constipation is discussed as a consequence of inner heat
decreasing the volume or weight of stool and develops
a sense of incomplete evacuation[38]. However, chronic

Table 1 Yin-deficiency presentations of diabetes mellitus

Chen et al Yu et al Zhou et al Peng & Yuan Chen

Eighteen Yin-deficiency presentations Li 2004[33]
2007[27] 2007[34] 2010[14] 2011[35] 2012[32]
Involuntarily heavy sweating at night √
Very thin figure √ √ √ √
Feeling unwell with the hot temperature √ √
Feeling well with the cold temperature √
Feeling hot with body and/or hands √ √ √ √
Dry skin √
Palpitation √
Flush face and/or cheekbone √
Dried eyes and/or nose √
Mouth, lip, and/or throat are very dry √ √ √ √
Tongue is red, dry, and crack √
Dizziness √ √
Tinnitus √ √ √ √
Thirsty with adequate water and tea √ √ √
Feeling well with the cold water √
Still hungry after adequate food intake √ √
Constipation √ √ √ √ √
Scanty urine and it is yellow √

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constipation reduces quality of life[39]. Community surveys
suggest that chronic constipation is the most common
gastrointestinal symptom of DM[40]. In view of the clinical
presentations of Yin-deficiency type of BC in this review,
the special features of other recognized presentations
are above-normal temperature and subnormal humidity
associated.
3.2 Yang-deficiency presentation
Ten presentations of Yang-deficiency type of BC were
observed from six references[14,27,32–35]. “Chronic diarrhea”
was favored in four out of the six reference sources (Table
2) followed by “weak and painful or cold loin and knees”
and “frequent urination” in three references, “tiredness
and fatigue” and “cold four limbs” in two references. In
addition to the “feeling unwell with the cold temperature”
and “fluid retention”, “profuse to speak” was also
reviewed as being less recognized in the review.
“Chronic diarrhea” is commonly recognized in persons
with DM (Table 2). From the perspective of CM, diarrhea
occurs in the person with Yang-deficiency with “cold-
dampness” in the stomach when he has consumed food of
a cold nature, such as watermelon and refrigerated food
and drinks[41,42]. Furthermore, insulin is a hormone which
is of Yin (cold) nature[43]. Diabetic medication with its
stimulating effect on the body insulin helps stabilize the
balance of “hot” vs “cold” and “dryness” vs “dampness”.
Under a balanced state of the body temperature and
humidity, insulin is able to process the blood glucose
control. Extra stimuli, such as food of a cold nature might
convert the temperature and humidity into an imbalanced
state, resulting in a “cold-dampness” state in the stomach
likely causing diarrhea in persons with DM[44]. However,
von der Ohe[44] argued that diarrhea in persons with DM
might be due to anorectal dysfunction. It was concluded
in a study that the mechanisms of chronic diarrhea in DM
were multifactorial and that the small bacterial overgrowth
Table 2 Yang-deficiency presentations of diabetes mellitus
Chen et al Yu et al
Ten Yang-deficiency presentations Li 2004[33]
2007[27] 2007[34]
Tiredness and fatigue
Feeling unwell with the cold temperature
Flabby
Fluid retention
Profuse to speak
Weak and painful or cold loin and knees √ √
Cold four limbs
Frequent urination
Chronic diarrhea √ √
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should be considered in case of chronic diabetic diarrhea
because of its frequency was 43%[45]. CM and Western
medicine have different views on diabetic diarrhea and
updated studies on diabetic diarrhea are rarely reported.
3.3 Empirical findings of “unhealthy” BC presentations
in DM
A total of 32 “unhealthy” BC presentation items were
identified from an initial validation of the Yin-Yang
Assessment Questionnaire (YY-AQ)[31] after using the
empirical findings of a mixed method study conducted
by Wong et al[30], validated relevant questionnaires[46,47]
and relevant references [42,48]. The YY-AQ consists of
18 Yin-deficiency presentation items and 14 items for
Yang-deficiency type of BC (Table 3). This assessment
questionnaire has been undergoing further psychometric
test: comprehensibility, test-retest and internal consistency
reliabilities, item integration, construct validity including
total item analysis and exploratory factor analysis,
discriminant and convergent validities, defining its scoring
system for clinical significance, and responsiveness. It
aims to help healthcare professionals, such as dieticians
to early identify persons with DM and the “unhealthy”
presentations of Yin-deficiency, Yang-deficiency
or Yin-Yang-deficiency [31] . A Yin/Yang-enhancing
dietary therapy or program would then be provided for
regulation of the “unhealthy” BC presentations. It is
because the conventional dietary therapy for DM with
nutrition component as the main therapeutic element
has its limitations in the regulation of “unhealthy” BC
presentations[30].
4 Conventional dietary therapy
Conventional dietary therapy constitutes an important
intervention for persons with DM. Control of body
weight by managing energy intake with a moderate-
Zhou et al Peng & Yuan Chen
2010[14] 2011[35] 2012[32]
√ √
√ √
√
√
√
√
√ √
√ √ √
√ √
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Table 3 Presentations of Yin-deficiency and Yang-deficiency
Eighteen Yin-deficiency presentations
I have felt excessively warm in all seasons.
I have worn thin clothes due to feeling excessively warm.
I have intermittent hot and cold spells.
My face has been flushed with crimson red.
I have been thin and slim.
My palms or soles have felt hot.
I have had tinnitus.
I have dry cough.
I have experienced hot flush especially in the afternoon.
I have experienced sweating at night.
My stools have been dry and hard.
I have felt hungry even after big meals.
I have passed minimal volumes of urine that were
yellow colored.
I have always drunk water to quench my thirst.
My thirst could not be relieved by frequent water intake.
My skin has been very dry.
My eyes have felt very dry.
My lips have felt very dry.
Source: Wong YC & Pang MC[31]
carbohydrate and low-fat diet is an essential component
of DM management, with an aim to achieve stabilized
blood glucose level [49] and reduced risk of diabetic
complications[3,49]. Persons with DM can achieve good
blood glucose control if they follow the principle of
balanced diet with consistent amount of carbohydrate
50% to 55% [50] or 50% to 60% [3]. In the real world, a
person with DM and good motivation may likely take the
carbohydrate amount that is less than the recommended
target for thinking that the lower the carbohydrate
amount it is consumed, the lower the blood glucose level.
Study showed that glycated hemoglobin (HbA1c) levels
decreased sharply from a baseline of 10.9% ± 1.6% to
7.8% ± 1.5% at 3 months and to 7.4% ± 1.4% at 6 months
after a 30% carbohydrate diet in severe T2DM for 33
outpatients (15 males, 18 females; mean age: 59 years)[51].
One study showed that a 20% carbohydrate diet was
significantly superior to a 55% to 60% carbohydrate diet
with regard to bodyweight and glycemic control in two
groups of obese diabetes patients observed closely over
6 months[52]. The initial mean HbA1c was 8.0% ± 1.5%.
After 6, 12 and 22 months, HbA1c was 6.1% ± 1.0%,
7.0% ± 1.3% and 6.9% ± 1.1% respectively. After 44
months, mean HbA1c was 6.8% ± 1.3%. Another study
demonstrated that a loosely restricted 45% carbohydrate
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Fourteen Yang-deficiency presentations
I have had an aversion to cold in all seasons.
I have worn thick clothes due to my aversion to cold.
I have had an aversion to strong wind.
I have experienced heavy sweating.
My body looks puffy.
I have had pains on my knee, loin, shoulder, and back but feeling
better with heat application.
I have running nose or sneezing.
I have had clear sputum.
I have felt comfortable with hot drink.
I needed to wake up because of my diarrhea.
My stools have been loose or watery.
I have had diarrhea, itchy throat or cough after intake of cold food.
I have passed large volumes of colorless urine.
I have experienced bland taste in my mouth.
diet led to greater reduction in HbA1c compared to
high-carbohydrate diets in outpatients with mild T2DM
(mean HbA1c level: 7.4%) over 2 years [51]. Different
scholars and researchers have different views on the
percentage intake of carbohydrate for glycemic control.
In addition to the energy distribution in carbohydrates,
fat and protein, it is recommended to incorporate a low-
glycemic index (GI) diet (such as pasta products, oats,
beans and some fruits and vegetables) in combination with
weight-reducing diet[53]. GI measures how carbohydrate-
containing food raises blood glucose level[54]. That means,
food with carbohydrate content and a low GI does not raise
blood glucose level more than food with a medium or high
GI. In contrast, food with carbohydrate content and a high
GI raises blood glucose level more than food with a low
or medium GI. Moderation of carbohydrates, reduced fat,
low-GI diet and high-dietary fibre with varieties of fruits,
vegetables and whole grains are the dietary guidelines in the
conventional dietary practice for DM care.
Persons with DM are advised to increase the intake
of fresh fruit, vegetables and dietary fibre in order to
manage their blood glucose levels, lipid profiles and blood
pressure[3]. This practice of dietary therapy is also applied
in persons without DM to prevent or treat chronic diseases,
such as obesity, hypertension, cardiovascular diseases
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and stroke. Likewise, the ultimate goal of dietary therapy
in DM management is to prevent diabetic complications,
such as cardiovascular diseases or stroke [55]. A study
was carried out to observe the association between
conventional dietary therapy and stroke[56]. A total fat at
20% of calorie intake, increased fruits, vegetables and
grains were assigned to the intervention group, which
consisted of 48 835 women aged 50–79 years. The control
group was advised to follow the Dietary Guidelines
for Americans. After a six-year follow-up period, the
intervention group was found to have significant changes
in a reduced intake of total fat and an increased intake
of dietary fibre, fruits, vegetables and whole grains.
However, no association was observed between the
conventional dietary therapy and stroke (hazard ratio,
0.90; 95% confidence interval, 0.66–1.22 and hazard ratio,
1.01; 95% confidence interval, 0.86–1.18). A long-term
intake of a low-fat diet with an increased intake of dietary
fibre, fruits, vegetables and whole gains might not prevent
the occurrence of stroke in persons with or without DM.
Diets based on low-GI foods have come into vogue
lately. Clinical trials showed that a low-GI diet
significantly improved the 24-hour blood glucose profile
in T2DM[53]. A low-GI diet can improve blood glucose
control in DM without compromising hypoglycaemia.
However, a systematic review conducted by the Cochrane
Collaboration yielded conflicting recommendations
regarding the usefulness of a low-GI diet for DM care[57].
The American Diabetes Association has updated
several guidelines[54]. These guidelines rely on nutritional
components and variation of food groups. They are applied
to adults of all ages, genders, cultures and social classes
with DM. However, these guidelines do not provide a clear
and concrete direction on how the nutrition components
should be managed to meet the needs of persons with
DM. For example, there is no ideal percentage of calories
from macronutrients including carbohydrates, proteins
and fats for all people with DM; therefore, macronutrient
distribution should be based on the individual assessment
of anthropometric measurement, clinical evidence, current
eating patterns, preferences and metabolic goals[54]. This
is similar to CM practice, in which treatment strategy
has to be built on the individual assessment of BC[58–60].
It was pointed out by Zhang et al[61] that conventional
dietary therapy focuses on the calculation of nutrition
components in providing nutritional support for different
persons with DM to achieve blood glucose control. In
contrast, Chinese food therapy targets on food “natures”
and “flavors” concept for achieving the treatment goal in
regulating “unhealthy” BC. It is clearly comprehended
that conventional dietary therapy has its limitation in
regulating BC from a perspective of CM while Chinese
food therapy does not deal with nutrition components
July 2016, Vol 14, No.4 260
in the control of blood glucose levels. An integration of
conventional dietary therapy and Chinese food therapy
might be a future direction in dietary management of
chronic diseases, such as DM[58,62].
5 Chinese food therapy
In the theory of CM, food is one of the means in
regulating “unhealthy” BC. “Cold” vs “hot”, “hot”
vs “cold”, “nourishing” vs “dryness”, “desiccating”
vs “dampness”, “replenishing” vs “deficiency” and
“shedding” vs “excess” are the CM food treatment
strategies[5,63]. In this section, food natures, food flavors
and scientific evidence of BC regulation are reviewed.
5.1 Food natures
In CM, food has natures that influence BC by affecting
Yin-Yang balance[64–66]. They are cold, cool, warm, hot
and neutral natures [65,67,68]. The cold and cool natures
belong to Yin, while the hot and warm natures belong to
Yang[68]. One more type of food nature is neither cold or
cool nor hot or warm. It is called “neutral” or “even”, and
lies between the warm and the cool natures[69]. Food of
a neutral nature is mild or gentle and does not have any
influence on BC[67]. Yet, this food nature has not been the
focus of very much discussion in CM references.
The cold or cool nature of food is adaptable to the Yin-
deficiency type of BC[70] for its function in clearing heat
by cooling down the body temperature and restoring body
fluid by raising the body humidity[58]. Producing fluid and
clearing heat is a treatment strategy for keeping one’s
body essence so as to either restore or prevent “heat-
dryness”[70]. A study of 163 T2DM cases with the Yin-
deficiency type of BC found that 63.2% of the intervention
group (diet of cold or cool nature in three months) had
improved presentations of “heat-dryness”, compared with
41.2% of the control group[71]. Food of a cold or cool
nature regulates the Yin-deficiency type of BC. However,
it is necessary to supplement foods of cold or cool natures
with hot or warm foods in order to enhance the restoration
of “heat-dryness”[72]. The dampness nature of cold or cool
foods, such as vegetables[64], retards the blood circulation,
resulting in turbid stagnation and disruption of the
digestive function. However, it is difficult to produce body
fluid unless food of a hot or warm nature, such as spice,
is added[72]. This argument is supported by the Yin-Yang
interdependence theory of CM that “Yin (cold) grows
while Yang (hot) is in vigor, and Yin becomes deficient
while Yang is weakened”[9]. The theory is also supported
by Wong’s descriptive correlation study in a sample of
140 persons with T2DM (Yin-deficiency and Yin-Yang-
deficiency: ρ = 0.91, P = 0.000; Yang-deficiency and
Yin-Yang-deficiency: ρ = 0.92, P = 0.000)[2]. Yin food
restores the Yin-deficiency type of BC and Yang food
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may be supplemented to a certain extent in enhancing the
restoration of body fluids.
Hot or warm natures of food may regulate a Yang-
deficiency type of BC so as to dispel inner “cold”[66,68].
CM scholars and practitioners discourage people with a
Yang-deficiency type of BC from consuming cold and raw
foods (uncooked food including raw seafood, fruit and
raw vegetables) due to their cold or cool natures[4,5,41,42,73].
The main reason is that cold and raw foods may harm
the spleen/stomach, which in turn retards the digestive
function[70], resulting in spleen/stomach-related symptoms,
such as diarrhea [41] and/or oedema [42] that are Yang-
deficiency type of presentations from a CM perspective[32].
The results of a pilot case control study for a duration
of six months showed that 45% of 20 participants in
the raw food diet group exhibited spleen qi-deficiency
(spleen dysfunction caused by the cold nature of spleen)
compared to 52% of 20 participants in the control group.
Furthermore, the study found that 11% of those who ate
more than 90% of raw foods for more than five years had
the least evidence of spleen-deficiency (disordered spleen
function)[74]. Although this study was conducted with a
small sample size and some experienced least spleen-
deficiency with more than 90% raw food intake for a long
time, a long-term food intake of cold and raw food might
probably harm the spleen/stomach from the perspective of
CM. The researchers suggested that further research was
required to find scientific evidence. In order to regulate
a Yang-deficiency type of BC, hot or warm natured
food is suggested in CM[42,68]. It is, however, necessary
to control the frequency and quantity of food intake
with hot or warm natures[58]. Furthermore, a little food
of a cold or cool nature has to be supplemented into the
foods of hot or warm nature. Otherwise, an imbalanced
state of temperature and humidity is likely to promote
Yin-deficiency, resulting in a Yin-Yang-deficiency
type of BC in accordance with the theory of Yin-Yang
interdependency[9,11].
5.2 Food flavors
In CM, foods have flavors that influence BC through
Yin-Yang balance[64,65]. They are the sweet, sour, bitter,
acrid and salty flavors[67]. In this section, food flavors
are discussed in relation to their functions, the involved
organs, adverse reactions, their influence on BC and
relevant food types. Sweet flavor exists in the majority of
foods, followed by salty and sour flavors, then acrid and
bitter flavors[68].
Sweet flavor nourishes the spleen/stomach and build up
strong muscles[9]. It functions by moistening the organ,
resulting in raising its humidity state. CM says that the
sweet flavor plays an important role in nourishing the
vital energy and blood[67]. Shen et al[66] applied CM food
therapy in a group of people with hypertension and Yin-
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deficiency by providing a menu offering foods with a little
sweet flavor. The sweet flavor nourished the “dryness”,
resulting in a balanced state of body humidity. A little
sweet flavor is adaptable to the Yin-deficiency type of
BC. Too much sweet flavor will, in turn, harm the organs,
causing a feeling of oppression in the heart[9] as a result
of fluid over-loading in the stomach extending to other
parts of the body[40], thus a phlegm-dampness type of BC
is likely to be induced[75]. Sweet flavor is found mostly
in cereals, sugar and honey[64]. In conventional dietary
therapy, the moderation of carbohydrate intake (50%–
60%), with a majority of cereals and very less sugar as a
main source of energy, is recommended to all adults with
DM[3]. Moderation of cereals and consuming less sugar
with a sweet flavor help maintain a balanced state of body
humidity, while excessive intake might lead to a phlegm-
dampness type of BC.
Salty flavor nourishes the kidney and goes to the blood
stream[9]. It dissipates a mass nourishing Yin and suppressing
Yang[58]. In the study conducted by Shen et al[66], seafood
such as jellyfish, oysters, mussels and laver were used as
supplementary foods to regulate the Yin-deficiency type
of BC. These types of food are cold or cool in nature with
a salty flavor[64] and good sources of protein[3]. A little
salty flavor helps clear inner “heat” and is adaptable to the
Yin-deficiency type of BC. However, when one takes the
salty flavor excessively, he or she will be thirsty[9]. Similar
to the sweet flavor, a little salty flavor regulates “heat-
dryness”, but too high an intake of salty flavor might
elevate the level of “heat-dryness” presenting with “thirst”.
Sour flavor nourishes the liver and strengthens
tendons [9] . It has the function of being astringent,
contracting and controlling diarrhea[68]. It controls the
loss of body fluid. Shen et al[66] made use of two kinds of
fruits, the pear and the kiwi, as a supplement to the menu
given for regulating the intervention group with a Yin-
deficiency type of BC. Pear and kiwi are cold in nature,
with a sour flavor[64]. Similar to the sweet and salty flavors,
the sour flavor replenishes “heat-dryness” by controlling
the loss of body fluid. However, an excessive intake of
sour flavors leads to dysuria, as the bladder will encounter
shrinking with sour flavor[9]. Similar to the sweet and salty
flavors, sour flavor helps regulate the Yin-deficiency type
of BC. Too high an intake of sour flavor might adversely
cause phlegm-dampness as a result of fluid retention
inside the body.
Acrid flavor strengthens the lung and promotes blood
circulation [9]. It disperses and regulates vital energy
by promoting the blood circulation [68]. Foods of hot or
warm natures with acrid flavors were pointed out by
Shen et al[66] to be avoided in persons with a Yin-deficiency
type of BC; these include ginger, black pepper, onion, garlic
and mutton. In contrast, acrid flavor could be adopted to
July 2016, Vol 14, No.4
 www.jcimjournal.com/jim
regulate a Yang-deficiency type of BC.
Bitter flavor nourishes the heart and promote healthy
bones[9]. It has a cooling effect by clearing “heat” and
drying “dampness”[68]. Green tea was used in the menu
developed by Shen et al [66] to help regulate the Yin-
deficiency type of BC in the intervention group. This food
type is of a cold nature, with a bitter flavor[76]. Bitter flavor
supports the control of subnormal body temperatures.
However, when one takes the bitter flavor excessively, he
or she will vomit[9,77]. Similar to the sweet, salty and sour
flavors, a little bitter flavor can be adaptable to the Yin-
deficiency type of BC only.
5.3 Scientific evidence on BC regulation
Kuang et al [78] carried out an experiment on the
regulation of BC in two groups of mice with healthy BC.
One group of mice was fed on ice cream (cold nature)
and the other group was given spices (hot nature), for
a period of six months. At the end of six months, the
results showed that the mice fed on the ice cream had
decreased enzyme activity of Na+-K+-ATP, while those
fed on the spices had increased enzyme activity of Na+-
K+-ATP. The increased enzyme activity implied that the
BC had changed from a cold-hot balanced nature to one
of excess heat, with a deficiency in cold. The decreased
enzyme activity, on the other hand implied that the BC
changed from a cold-hot balanced state to excess cold
and deficiency in heat. Subsequent to the changes of BC,
the investigators tested the effects of food natures on BC
by feeding spices to mice with cold BC and ice cream to
those with hot BC. It was shown that mice with both BC
types had come to a balanced cold and hot presentation.
This animal model of study supports the theory that BC is
influenced by intake of foods with hot or cold natures.
A test was performed on dietary therapy on a group of
80 children with Yin-deficiency type of BC[79]. They were
asked to start diets of a cold/cool nature with sweet, salty,
sour and bitter flavors. Foods of a hot/warm nature and
acrid taste were avoided. After six months, the results
showed that the upper respiratory illness which was
prevalent in the children, showed a downward trend of
Yin-deficiency presentations. These results supported that
a cold/cool food nature, together with sweet, salty, sour
and bitter flavors, can regulate a Yin-deficiency type of
BC.
Chao et al [80] conducted a study on the effects of
water (neutral nature), aged ginger tea (hot nature),
and coconut water (cold nature) on signals of heart rate
variability and nail fold microcirculation of 19 young
persons with Yin-deficiency types of BC and 11 with
Yang-deficiency types of BC. The results showed that
the skin temperatures of the Yin-deficiency group,
after taking coconut water, were significantly reduced
compared to their skin temperatures after taking water
July 2016, Vol 14, No.4 262
or aged ginger tea (–10.1%, P < 0.05). The capillary
red blood cell velocity in nail fold microcirculation
of the Yang-deficiency group accelerated significantly
after taking aged ginger tea compared with taking water
or coconut water (+16.6%, P < 0.05). The capillary
red blood cell velocity in nail fold microcirculation
of the Yin-deficiency group decelerated significantly
after taking coconut water compared with taking water
or aged ginger tea (–26.7%, P < 0.05). This finding
suggested that food of a hot/warm nature is adaptable
to the Yang-deficiency type of BC, while the Yin-
deficiency of BC requires food of a cold/cool nature
and its therapeutic effect by BC regulation.
A study was conducted on 136 cases with T2DM and
Yin-deficiency types of BC by suggesting food types with
a combination of cold/cool nature with sweet (vegetables),
salty (seaweeds) and sour (citrus fruits and pear)
flavors[71]. Cooking methods were restricted to steaming,
boiling, blending and braising only. The results showed
that the 63.2% of the Yin-deficiency group had improved
presentations more than 41.2% of the control group. The
study results also suggested that choice of foods and
cooking methods play an important role in the regulation
of BC.
6 Empirical evidence on need of integrated
dietary therapy in diabetes management
An empirical study was conducted by Wong et al[2,30]
on the association between BC and food intake from a
perspective of CM. It was a two-phase mixed method
design including an exploratory case study using
multiple cases (n = 18) between May 2011 and June
2011 and descriptive correlation study using a structured
questionnaire survey (n = 140) between October 2013
and December 2013. The study methods and results are
described as follows.
6.1 Methods
6.1.1 First phase
Eighteen persons with T2DM were recruited after they
had met the inclusion criteria: aged over 18 years; not
on insulin injection; no other chronic diseases and other
medical treatments, such as non-diabetic medications,
kidney dialysis, chemotherapy, radiotherapy or Chinese
tonification. Each participant prepared a record of his
or her food intake for a period of seven days, followed
by receiving BC assessment from a registered Chinese
medicine practitioner who has 25 years of clinical
experience in CM. Each case was then analyzed covering
BC type and presentations, food intake in natures and
flavors and demographic and health characteristics. Cross-
case analysis was performed across cases within similar
BC types and among different BC types.
Journal of Integrative Medicine

6.1.2 Second phase
Based on the results of the first phase, the YY-AQ and
Food Intake Questionnaire (FI-Q) were devised. These
two questionnaires had initially passed the tests for
content validity, comprehensibility, test-retest reliability
and internal consistency reliability. At the survey of the
descriptive correlation study, a total of 140 participants
were recruited after they had met the recruitment criteria:
T2DM, aged over 18 years, not on insulin injection
and other medical treatments, such as kidney dialysis,
chemotherapy or radiotherapy. Each participant was asked
to fill in the YY-AQ, FI-Q and a modified demographic
and health characteristics questionnaire by themselves,
followed by data check by the researcher or trained
helpers. Spearman’s correlation coefficient (Spearman’s
ρ) was used to analyze the correlation between the
presentations of Yin-deficiency, Yang-deficiency, Yin-
Yang-deficiency and natures of food intake as well as
among the different types of deficiency presentations. A
value of P < 0.05 was considered statistically significant.
Independent sample test was used to analyze the
association between presentations of Yin-deficiency, Yang-
deficiency, Yin-Yang-deficiency and chronic diseases,
non-diabetic medications, age, gender, years of known
DM diagnosis and body weight.
6.2 Results
Results of the exploratory case study in the first phase
are as follows [2,30] . First, 11 Yin-deficiency type of
presentations and 17 Yang-deficiency type of presentations
were identified. Second, three cases with Yin-deficiency
and higher intake of “hot” foods, 12 cases with Yang-
deficiency and higher intake of “cold” foods and three
cases with Yin-Yang-deficiency and higher intake of
“cold” foods were found. Cross-case analysis results are
summarized in Table 4. It was found that those with Yang-
deficiency or Yin-Yang-deficiency tended to consume
more vegetables being cooked without ginger and garlic
(“hot” food), pan-fried meat (“hot” food) in small quantity
or moderation, soup of cold nature, more fruits (mostly
“cold” food), and cold beverages. These food types and
eating patterns are, however, acceptable in conventional
dietary therapy not because of their natures but due to
their low fat and high fiber contents. Conventional dietary
therapy only deals with nutrition component[2]. Since the
Yin-deficiency cases tended to eat a lot of pan-fried meats,
less vegetables and fruits, such eating pattern is also not
advisable in conventional dietary therapy[2].
The results of the descriptive correlation study in the
second phase showed that the Yin-deficiency presentations
had small correlation with the “hot” food intake
(Spearman’s ρ: 0.35, P = 0.000) but not with the “cold”
food intake (Spearman’s ρ: 0.14, P = 0.11)[2]. The Yang-
deficiency presentations had positively weak correlation
Journal of Integrative Medicine 263
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with the “hot” food intake (Spearman’s ρ: 0.21, P = 0.014)
but not with the “cold” food intake (Spearman’s ρ: 0.2,
P = 0.005). Similar to the Yin-deficiency presentations,
the Yin-Yang-deficiency presentations also had small
correlation with the “hot” food intake (Spearman’s ρ:
0.30, P = 0.001) but not with the “cold” food intake
(Spearman’s ρ: 0.16, P = 0.06). The Yin-deficiency and
Yang-deficiency presentations had moderate to high
correlation with each other (Spearman’s ρ: 0.71, P =
0.000). The Yin-Yang-deficiency presentations had very
high correlations with the Yin-deficiency presentations
(Spearman’s ρ: 0.91, P = 0.000) and the Yang-deficiency
presentations (Spearman’s ρ: 0.92, P = 0.000). “Other
chronic diseases” and “non-diabetic medications” showed
statistically significant associations with the presentations
of Yin-, Yang- and Yin-Yang-deficiency, respectively
(P < 0.005) but not the gender, age, body weight and
years of known diagnosis (P > 0.005). The mean value
for “hot” food intake was found to be at a moderate score
level (13.0 ± 5.4) and “cold” food intake showed a mean
score of 15.0 ± 5.0, which was also a moderate level.
Based on the above findings, it is comprehended that the
presentations of Yin-deficiency, Yang-deficiency and Yin-
Yang-deficiency were potentially influenced by “other
chronic diseases” which is associated with “unhealthy”
BC [81], “non-diabetic medications” as medicine also
has natures and flavors [82] and the theories of Yin-
Yang interdependence and Yin-Yang mutual transfor-
mation[10,12,16], but not the “hot” and “cold” food intakes
in the study. However, the moderate intake of “hot”
food intake was not able to regulate the Yin-deficiency
presentations and Yin-Yang-deficiency presentations and
insufficient to regulate the Yang-deficiency presentations.
In order to regulate the “unhealthy” BC presentations for
persons with DM, high intake of “cold” food is advisable
for Yin-deficiency (Table 5), “hot” food for Yang-
deficiency (Table 6) and “neutral” food for Yin-Yang-
deficiency (Table 7)[2].
7 Conclusion
“Unhealthy” BC presentations exist in persons with
DM. From a perspective of CM, food has natures
and flavors that can help regulate “unhealthy” BC
presentations. However, the current practice of dietary
therapy for DM has its limitations in dealing with
“unhealthy” BC presentations due to focusing on
nutrition component only. Integration of conventional
dietary therapy and Chinese food therapy could be
a new treatment strategy for either stabilization of
blood glucose level or regulation of “unhealthy” BC
presentations for persons with DM or other chronic
diseases. It would be necessary to test the effectiveness
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of an integrated approach of dietary therapy for persons
with DM after further validation of the YY-AQ. The
ultimate goal of the integrated dietary approach is to
reduce the disease burden, such as disease-related poor
quality of life, stress of healthcare professionals and
the rising of healthcare cost for chronic diseases.
8 Conflicting interests
The author declares that there is no conflict of interest.

Table 4 Summary of cross-case analysis results of exploratory study

Food group Three Yin-deficiency cases Twelve Yang-deficiency cases Three Yin-Yang-deficiency cases
Cereals 2 cases: less than ¾ bowl rice 6 cases: less boiled rice One case: less boiled rice
Meats and eggs High intake of pan-fried meats Pan-fried meats in small Steamed pork and fish only
or moderation
Vegetables and Small intake High intake of boiled vegetables High intake of boiled vegetables
melon without ginger and garlic without ginger and garlic
Fruit Small intake More intake More intake
Soups More “hot” nature More “cold” nature Seldom
Beverages Less “cold” drinks More “cold” drinks High intake of “cold” drinks
Snacks More “hot” natured snacks More “cold” natured snacks Seldom
Frequency “Hot” foods ≥ 3 times in 7 d “Cold” foods ≥ 3 times in 7 d “Cold” foods ≥ 3 times in 7 d

Table 5 Suggested meal plan for regulating Yin-deficiency

Food Nature
Meal Food
“Hot” “Neutral” “Cold”
Breakfast Oat meal porridge with dried risins √
Macaroni in soup with pork meat √ √
Pork meat congee √
Steamed pork meat bun √
Lunch Boiled rice √
Steamed fish with little ginger √
Boiled vegetables without ginger and/or garlic √
Kiwi √
Dinner Boiled rice √
Steamed pork meat cake √
Boiled vegetables and mushroom without ginger and/or garlic √
Soybean and kelp soup √
Orange √
Snack Apple √
Skim milk √
Plain biscuit and green tea/fruit tea √ √
Bread 1 slice with raisin √ √
Beverage Green tea √
Fruit tea √
Lemon in cold water √ √
Lemon in hot or cold tea √
Bitter melon tea √
Peppermint tea √
Drinking water 6–8 glasses per day.

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Table 6 Suggested meal plan for regulating Yang-deficiency

Food Nature
Meal Food “Cold”
“Hot” “Neutral”
Breakfast Toast with pan-fried egg (not oily) √
Fried rice noodle in soup with chicken meat (less cooking oil) √ √
Lunch Boiled rice √
Pan-fried fish with ginger or chilli sauce (less cooking oil) √
Shallow fried vegetables with ginger and/or garlic (less cooking oil) √
Guava √
Dinner Boiled rice √
Steamed chicken (skin off) √
Shallow fried vegetables with ginger and/or garlic (less cooking oil) √
Beef and assorted vegetables soup √
Apple √
Snack Grapes √
Skim milk √
Plain biscuit √
Bread √
Walnut √
Beverage Coffee √
Red tea √
Black tea √
Lemon in hot water √
Ginger and lemon in hot water √ √
Drinking water 4–6 glasses per day.

Table 7 Suggested meal plan for regulating Yin-Yang-deficiency

Food Nature
Meal Food
“Hot” “Neutral” “Cold”
Breakfast Pork meat congee √
Steamed rice roll √
Steamed pork meat bun √
Lunch Boiled rice √
Steamed pork meat with mushroom and fungi √
Stirred fried vegetables without ginger and/or garlic (less cooking oil) √
Apple √
Dinner Boiled rice √
Steamed fish with ginger and mandarin peel √
Stirred fried vegetables without ginger and/or garlic (less cooking oil) √
Chinese yam, lotus seeds and pork meat soup √
Grapes √
Snack Pineapple √
Skim milk √
Plain biscuit 2 pieces and green tea √ √
Steamed chicken meat bun √ √
Plain bread with ham and/or low-fat cheese √ √
Beverage Lemon in hot water √
Red tea √
Black tea √
Ginger and lemon in water √ √
Drinking water 4–6 glasses per day.

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Zhongguo Zhong Yi Ji Chu Yi Xue Za Zhi. 2012; 17(12):
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