【作者】 宫晴；

【导师】 赵进喜；

【作者基本信息】 北京中医药大学 ， 中医内科学， 2012， 博士

【摘要】 三阴三阳体质分类方法是导师赵进喜教授在研究《内经》理论并继承《伤寒论》三阴三阳辨证方法的基础上,结合临床实际,提出的一种体质分类方法由于体质在疾病发生、发展过程中发挥重要作用,辨体质类型可作为一种临床思路,协助辨证选方用药,判断易感病症及疾病发展趋势,并可指导养生防病。三阴三阳体质分类作为一种临床上有实用价值的体质分类方法,在对其进行研究和评价的过程中首先需要一个有效的量表作为测量工具,这也是进一步研究的前提。本课题主要分为两部分,第一部分编制三阴三阳体质初量表,第二部分应用初量表进行2型糖尿病与体质的相关性分析,现摘要如下1文献综述：对中医体质分类研究的概况、糖尿病及其并发症与中医体质的相关性研究进展作了较为系统的总结。2理论研究：结合《伤寒论》相关内容,较为详尽地阐述了三阳三阳系统论和体质论的内涵。阐释三阴三阳各系统的生理功能与病理表现,指出三阴三阳体质类型是因人体三阴三阳六系统生理功能不平衡所形成的,故病理状态下即易出现相应系统的临床表现。3三阴三阳体质判定量表的初步编制：目的旨在初步建立以三阴三阳体质分类方法为理论基础的体质判定量表该量表以一般人群为研究对象,目的在于了解个体体质类型,属普适性量表方法按照自制量表的编制步骤进行。首先确立三阴三阳体质类型的概念内涵,并通过文献调研与集体讨论进行量表条目的收集,形成条目池,对各亚量表条目进行赋权,决定判定标准,形成初始量表；通过访谈、讨论、小范围调查对量表条目进行分析并初步筛选及修改,形成修改后量表；进行问卷调查对符合条件的711例样本条目进行分析,并对修改后量表进行性能评价。结果①对各亚量表条目分主次进行3：1赋权,采用定性与定量结合的方法,按照判定规则结合各亚类型得分进行体质判断。②量表条目筛选结果：对711例样本进行量表条目困难度、反应度、敏感性、集中趋势分析及探索性因子分析等,结合多种方法,对条目进行筛选。形成4个领域17个方面,49个条目的初量表。③初量表重复测量信度的考察：20例重复测量相关系数r=0.787,p=0.007,两次得分值呈正相关,有显著性统计学意义,提示量表的重测信度良好。④初量表的内容效度考核：对620例体质问卷逐份进行经验判断,与通过计算分数判断的结果进行比较。采用定性与取高值相结合的方法,二者符合率为80.3%,与单纯分数判定相比,效度相对较高。结论三阴三阳体质判定初量表经过条目分析及筛选,具有较好的重复测量信度,采用定性与定量结合的判定方法,内容效度相对较高,可初步用于三阴三阳体质类型的判定。4三阴三阳体质与2型糖尿病相关性分析：目的通过2型糖尿病人群及非糖尿病普通人群的病例对照研究,引入量表方法分析其三阴三阳体质分布特点、饮食生活习惯及目前证候、理化检查等,采用数理统计方法进行体质与诸多因素的相关性研究,探讨糖尿病人群易感体质及不同体质人群的糖尿病发病特点,为临床实践中辨体质与辨病、辨证“三位一体”诊疗模式提供依据。方法按照调查病例标准纳入310例2型糖尿病及310例非糖尿病一般人群,采集一般资料,要求2型糖尿病患者回忆患病前较长一段时间的情况,填写三阴三阳体质初量表,并对其进行证候判定,收集其他临床资料。非糖尿病一般人群根据自身感觉填写体质量表。使用SPSS18.0对数据进行统计处理。计数资料用x2检验,非正态计量资料和等级资料用秩和检验,因素分析采用Logistic回归分析。结果①糖尿病组单一体质六大类型百分比由高到低依次为太阳体质(9 0例,29.0%),阳明体质(74例,23.9%),少阳体质(52例,16.8%),厥阴体质(46例,14.8%),少阴体质(26例,8.4%),太阴体质(18例,5.8%)。非糖尿病组单一体质六大类型百分比由高到低依次为太阳体质(99例,31.9%),阳明体质(37例,11.9%),少阳体质(48例,15.5%),厥阴体质(47例,15.2%),太阴体质(41例,13.2%),少阴体质(33例,1 0.6%)。糖尿病组与非糖尿病组相比,阳明体质与太阴体质频次有显著性差异,糖尿病组阳明体质较非糖尿病组为多(p<0.01),而太阴体质较非糖尿病组为少(p<0.0 1)。其余体质类型差异无统计学意义(p>0.05)。②糖尿病组与非糖尿病组偏热性体质与非热性体质间具有显著性差异,相对于非糖尿病人群,糖尿病人群偏热性体质较非热性体质人数为多(p<0.01),两组偏寒性体质与非寒性体质间差异无统计学意义(p>0.05)。两组实性体质与虚性体质间具有显著性差异,相对于非糖尿病组,糖尿病组实性体质较虚性体质人数为多(p<0.01)。③糖尿病组与非糖尿病组体重指数比较具有显著性差异,糖尿病组高于非糖尿病组(p<0.01)；糖尿病组嗜烟者多于非糖尿病组,具有显著性差异(p<0.01)；饮酒嗜好两组无显著性差异(p>0.05)；糖尿病组在喜食油腻、辛辣、咸、甜饮食方面较非糖尿病组多,非糖尿病组在喜食酸性食物方面较糖尿病组多,均有显著性差异(p<0.01)。在饮食偏淡、饮食偏苦方面两组无统计学差异(p>0.05)；糖尿病组较非糖尿病组不经常进行主动运动锻炼,两组具有显著性差异(p<0.01)。④两组合并后对体质的性别差异分析：少阳体质、太阳体质、厥阴体质频次差异均有统计学意义,少阳体质女性比男性明显偏多(p<0.01),厥阴体质女性比男性偏多(p<0.05),太阳体质男性比女性偏多(p<0.05),具体分析,糖尿病组太阳体质无性别差异(p=0.901),非糖尿病组男性比女性偏多(p=0.001)。⑤糖尿病组内的比较：将少阳体质、阳明体质血脂、血糖水平分别与太阳体质比较,少阳体质HbAlc与太阳体质比较有显著性差异(p<0.05),其余指标两组间比较未见显著性差异(p>0.05)。310例2型糖尿病患者中的238例同时进行了证候判断,对其中样本量大于40的少阳、阳明、太阳体质的证候频率分布进行比较。结果可见少阳体质与太阳、阳明体质比较,出现气郁证的频率较后两者为多(均为p<0.01),出现气虚证的频率较后两者为多(与太阳体质比较p<0.01,与阳明体质比较p<0.0 5)；阳明体质与太阳、少阳体质比较,出现结热证的频率较后两者为多(均为p<0.05)。余证候体质两两比较未见统计学差异(p>0.05)。1ogistic回归分析结果显示,气郁证与少阳体质糖尿病患者呈显著正相关(B=1.536,0R=4.645),气虚证与少阳体质糖尿病患者呈显著正相关(B=1.213,0R=3.362)；结热证与阳明体质糖尿病患者呈显著正相关(B=1.225,0R=3.405)。结论①2型糖尿病人群患病前阳明体质者较多,太阴体质者较少。②2型糖尿病人群患病前以热性体质及实性体质偏多,从体质角度支持糖尿病“内热伤阴”病机学说。③肥胖、嗜烟、高脂高热量饮食、运动量少是糖尿病的危险因素。④少阳体质与厥阴体质男女比例有明显差异,均为女性多于男性；男性太阳体质较女性为多尚待进一步研究证实。⑤少阳体质糖尿病患者出现气郁证者较其他体质人群更为多见,阳明体质患者出现结热证较其他体质人群更为多见。初步证明证候与体质类型间具有趋同性,即体质“从化”现象的存在。更多还原

【Abstract】 The physical classification of three yin and three yang was based on the clinical practice and put forward by my tutor professor Zhao Jinxi who researched the theory in Huangdi’s Canon of Medicine and the method of three yin and three yang syndrome differentiation in Diseases Caused by Cold Factors. Distinguishing the type of constitution as a clinical thought can assist the differentiation of symptom-complexes and choosing drugs, judge susceptible diseases and development tendency of them, because constitution plays an important role in the process diseases. Besides, it can also guide health care. Because the three yin and three yang constitution is a valuable clinical classification method, the first thing is to establish an effective scale as measurement tools, this also is the premise of further studies. The study was divided into two parts, the purpose of the first part was to establish an early scale of three yin and three yang constitution, and tha of the second part was to analyze the correlation of constitution and type 2 diabetes. The abstract as follows:1 Literature review:The general situation of the study of classification of constitution in Chinese medicine and the process in correlation between constitution and diabetes and its complications were made a more systematic summary.2 Theory research:The connotation of three yin and three yang system theory and the physical theory were both relatively expounded according to the related content on Diseases Caused by Cold Factors. The physiological functions and pathological performance of each system of three yin and three yang were explained. The constitution type is formed because of the imbalance of the three yin and three yang system in human body. So the clinical manifestations of the corresponding system would be common in the pathologic state.3 The preliminary establishment of three yin and three yang constitution determination scale:Objective:Set up a preliminary determination scale based on the three yin and three yang physical classification method. The respondents are general population, and the purpose is to understand the individual type of constitution. It’s a scale with universality.Methods:The research was done according to the step of the study of a homemade scale. The first step is to establish the concepts of three yin and three yang type of constitution, and collect items of the scale through literatures and discussion, and form an items pool. Weights of items in subscales were given. The standards of determination were decided, and the initial scale was formed; Items were filtered and modified preliminarily through the methods of interview, discussion and little scope of survey. Then a modified scale was formed; Then a survey 711 cases was been made, items were analyzed once again and the performance of the modified scale was evaluated.Results:(1) The items in the subscale were given weights and the proportion was 3:1 according to primary items and secondary ones. (2) Results of items screening:Items in 711 cases of sample were analyzed with many methods such as reaction degree of difficulty, reaction degree, sensitivity, concentrated trend analysis and exploratory factor analysis. A scale with 49 items including 4 areas and 17 facets was formed. (3) The test-retest reliability of the initial scale:20 cases did the scale twice, and the correlation coefficient r=0.787, p=0.007. The two scores were positively associated and the result has statistical significance which indicated that the test-retest reliability of the scale is good. (4) Content validity of the early scale:The types of constitution of 620 cases were judged by experience. The results were compared with that judged by the score. The anastomotic rate of the two methods was 80.3% taking the method of combining the qualitative and quantitative determination. Compared with the pure scores determination, the method of combining the qualitative and quantitative determination had higher validity.Conclusion:The early scale of three yin and three yang constitution which through items analysis and screening has good test-retest reliability. With the method of combining the qualitative and quantitative determination, the content validity is higher. The scale can be used preliminarily in judgement of the type of three yin and three yang constitution.4 The correlation between three yin and three yang constitution and type 2 diabetes:Objective:Through the case-control study with people with type 2 diabetes and the general population, introducing the scale method to analyze the distribution of three yin and three yang constitution characteristics, dietary habits and the present syndrome, physical and chemical examination, etc. To study the correlationship of constitution and many other factors by the mathematical statistic method. To explore the type of the susceptible constitution of diabetes and the characteristics of the risk factors of diabetes in different types of constitution. To provide the basis for the diagnosis and treatment model of the "trinity" including constitution, syndrome and disease differentiation in clinical practice.Methods:Both of 310 cases type 2 diabetes and general population were received according to the standard. The general information of the two groups was collected. Patients with type 2 diabetes were required to recall the state a long period before disease, fill the scale, and judgement of syndromes was done, and other clinical data were collected. General population filled the constitution scale based on their own feeling. The data were analyzed by SPSS18.0. Count material with the chi-square test, non-normal measurement data and grade material with rank sum test, and Logistic regression analysis was used in factors analysis.Results:(1) The frequency of yangming constitution and taiyin constitution of diabetic group was significant different from that of non-diabetic group. Yangming constitution of diabetic group was more than that of non-diabetic group (p<0.01), and taiyin constitution of diabetic group was less than that of non-diabetic group (p<0.01). Differences of the rest types of constitution had no statistically significance (p>0.05).(2) Compared with that of the non-diabetic group, people of thermal types of constitution was more than non-thermal types of constitution of diabetic group (p<0.01). There was no statistical significance between non-cold constitutions of the two groups (p>0.05). Compared with that of the diabetic group, the great constitution of diabetic group was more than the weak constitution (p<0.01).(3)BMI of diabetic group was higher than that of non-diabetic group (p<0.01); People who smoke in diabetic group were more than that of non-diabetic group (p<0.01); There was no significant difference between the two groups in drinking habits (p>0.05); in diabetic group, people who loved eating greasy, hot, salty, sweet food were more than that of non-diabetic group (p<0.01). There was no statistical differences between the two groups on bitter or light diet (p>0.05); People who have diabetes did less sports exercise than people who have no diabetes (p<0.01).(4) There were more women who had shaoyang constitution than men (p<0.01) and more women who had jueyin constitution than men (p<0.05).(5) Compared with people who had taiyang or yangming constitution, people who had shaoyang constitution had more chance to express as qi stagnation syndrome (both p<0.01). Compared with people who had taiyang or shaoyang constitution, people who had yangming constitution had more chance to express as heat and solid syndrome (both p<0.05).Conclusion:(1) Yangming constitution is a susceptible type of constitution for type 2 diabetes, and taiyin constitution is harder to suffer type 2 diabetes. (2) The type of constitution of people with type 2 diabetes is mostly thermal and solid constitution, which supports "hot injury yin" theory of diabetes from physical perspective. (3) Obesity, smoking, fat food of high calorie, and less movement are risk factors for diabetes. (4) There are obvious differences in frequency of shaoyang and jueyin constitution in sex. There are more women than men; There were more men of taiyang constitution than women but it is yet to be further study. (5) In diabetic people of shaoyang constitution, there are more qi stagnation syndrome than other people; In diabetic people of yang ming constitution, there are more heat and solid syndrome than other people. It is a preliminary evidence that syndrome and constitution have a trend of convergence.更多还原