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Journal of Traditional Chinese Medicine >

2026 , Vol. 46 >Issue 2: 480 - 489

DOI: https://doi.org/10.19852/j.cnki.jtcm.20250821.001

Original Articles

Tongue color tones in Traditional Chinese Medicine correlate with liver histology of metabolic dysfunction-associated steatohepatitis in morbidly obese patients undergoing metabolic and bariatric surgery

  • CEN Zhikang ,
  • HUANG Bing ,
  • ZHANG Pengfei ,
  • LIU Dongyang ,
  • MO Yanxin ,
  • ZHU Fei ,
  • FAN Mengqi ,
  • NI Zheng ,
  • XU Ying ,
  • LIU Wei ,
  • WU Shuduo ,
  • XU Aimin ,
  • SONG Erfei ,
  • YE Dewei
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  • 1 Key Laboratory of Metabolic Phenotyping in Model Animals, Guangdong Pharmaceutical University, Guangzhou 510006, China
    2 Institute of Metabolic Science, Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou 510006, China
    3 School of Chinese Medicine, Guangdong Pharmaceutical University, Guangzhou 510006, China
    4 the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510400, China
    5 Division of Hepatology, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510120, China
    6 State Key Laboratory of Pharmaceutical Biotechnology, the University of Hong Kong, Hong Kong, China
    7 Department of Medicine, The University of Hong Kong, Hong Kong 999077, China
    8 Department of Bariatric Surgery, the First Affiliated Hospital of Jinan University, Guangzhou 510630, China
YE Dewei, Key Laboratory of Metabolic Phenotyping in Model Animals, Guangdong Pharmaceutical University, Guangzhou 510006, China. dewei.ye@foxmail.com; Telephone: +86-20-39353115;
SONG Erfei, Department of Bariatric Surgery, the First Affiliated Hospital of Jinan University, Guangzhou 510630, China. songerfei@jnu.edu.cn; Telephone: +86-20-38688610

Received date: 2025-03-31

  Accepted date: 2025-06-21

  Online published: 2025-08-21

Supported by

Immunometabolism Mechanisms Underlying the Development of Chronic Diseases and Therapeutic Benefits of Traditional Chinese Medicine(2024ZD0521005);Functional Investigation of Proteinase 3 in the Development of Diabetic Kidney Diseases and Mechanistic Insights into Therapeutic Benefits of Traditional Chinese Medicine Formula(82374171);Exploration of Pathogenic Role of Neutrophil Extracellular Traps in Increased Susceptibility to Drug-induced Liver Injury under Co-existing Metabolic Dysfunction-associated Steatohepatitis(2024A1515012945);Basic and Translational Investigation of Immunometabolism in Metabolic Diseases(SL2023A04-J01031);Key Laboratory of Model Animal Phenotyping and Basic Research in Metabolic Diseases(2018KSYS003)

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Abstract

OBJECTIVE: To determine the association of tongue color tones in morbidly obese patients with various liver histological characteristics of metabolic dysfunction-associated steatohepatitis (MASH), which is the advanced subtype of metabolic dysfunction-associated steatotic liver disease (MASLD).

METHODS: A total of 60 morbidly obese adults who underwent metabolic and bariatric surgery were recruited. Liver biopsies were available for all participants and were subjected to histological assessment. The association of tongue color tones with histological parameters in the liver was investigated.

RESULTS: MASH-related histological characteristics in the liver were closely associated with color features in distinct zones of the tongue. The values for color channels red (R), green (G), and blue (B) were increased in subjects with histological features of steatosis. Likewise, the histological characteristic of lobular inflammation was associated with distinct panels of RGB values for tongue edge zones and tongue coating. RGB values in the tongue exhibited a step-wise increase in line with grading score of liver histology. In contrast, tooth-sign on the tongue was dissociated with histological features of MASH.

CONCLUSION: Our clinicopathological study demonstrated a close association of color tones in the tongue with MASH-related histological characteristics in the liver of morbidly obese patients, supporting the application of tongue inspection in Traditional Chinese Medicine as a promising approach to non-invasive diagnosis of MASLD/MASH.

Key words： tongue inspection; obesity; liver histology; steatotic liver disease; tongue image

Cite this article

CEN Zhikang , HUANG Bing , ZHANG Pengfei , LIU Dongyang , MO Yanxin , ZHU Fei , FAN Mengqi , NI Zheng , XU Ying , LIU Wei , WU Shuduo , XU Aimin , SONG Erfei , YE Dewei . Tongue color tones in Traditional Chinese Medicine correlate with liver histology of metabolic dysfunction-associated steatohepatitis in morbidly obese patients undergoing metabolic and bariatric surgery[J]. Journal of Traditional Chinese Medicine, 2026 , 46(2) : 480 -489 . DOI: 10.19852/j.cnki.jtcm.20250821.001

References

1. Rinella ME, Lazarus JV, Ratziu V, et al. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. J Hepatol 2023; 79: 1542-56.
2. Younossi ZM, Golabi P, Paik JM, Henry A, Van Dongen C, Henry L. The global epidemiology of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH): a systematic review. Hepatology 2023; 77: 1335-47.
3. Musso G, Cassader M, Gambino R. Non-alcoholic steatohepatitis: emerging molecular targets and therapeutic strategies. Nat Rev Drug Discov 2016; 15: 249-74.
4. Harrison SA, Bedossa P, Guy CD, et al. A phase 3, randomized, controlled trial of resmetirom in NASH with liver fibrosis. N Engl J Med 2024; 390: 497-509.
5. Harrison SA, Allen AM, Dubourg J, Noureddin M, Alkhouri N. Challenges and opportunities in NASH drug development. Nat Med 2023; 29: 562-73.
6. Harrison SA, Dubourg J. Liver biopsy evaluation in MASH drug development: think thrice, act wise. J Hepatol 2024; 81: 886-94.
7. Bedossa P, Patel K. Biopsy and noninvasive methods to assess progression of nonalcoholic fatty liver disease. Gastroenterology 2016; 150: 1811-22.e1814.
8. Ji D. Analysis of tongue image in Traditional Chinese Medicine. Tianjin: Tianjin Science & Technology Translation & Publishing Co., Ltd., 2008: 1-9.
9. Laskin DM, Giglio JA, Rippert ET. Differential diagnosis of tongue lesions. Quintessence Int 2003; 34: 331-42.
10. Huang DQ, Wong VWS, Rinella ME, et al. Metabolic dysfunction-associated steatotic liver disease in adults. Nat Rev Dis Primers 2025; 11: 14.
11. Wang Y, Fleishman JS, Li T, et al. Pharmacological therapy of metabolic dysfunction-associated steatotic liver disease-driven hepatocellular carcinoma. Front Pharmacol 2023; 14: 1336216.
12. Chen M, Xie Y, Gong S, et al. Traditional Chinese Medicine in the treatment of nonalcoholic steatohepatitis. Pharmacol Res 2021; 172: 105849.
13. Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of nonalcoholic fatty liver disease: practice guidance from the American Association for the Study of Liver Diseases. Hepatology 2018; 67: 328-57.
14. Fan M, Song E, Zhang Y, et al. Metabolic dysfunction-associated steatohepatitis detected by neutrophilic crown-like structures in morbidly obese patients: a multicenter and clinicopathological study. Research (Wash D C) 2024; 7: 0382.
15. Kleiner DE, Brunt EM, Van Natta M, et al. Design and validation of a histological scoring system for nonalcoholic fatty liver disease. Hepatology 2005; 41: 1313-21.
16. Tincopa MA, Loomba R. Non-invasive diagnosis and monitoring of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis. Lancet Gastroenterol Hepatol 2023; 8: 660-70.
17. Gao G, Li S, Xue J, et al. Traditional Chinese Medicine syndrome types and syndrome elements of nonalcoholic fatty liver disease. J Clin Hepatol 2021; 37: 89-93.
18. Zhao M, Peng H, Wang J, et al. Objectified study on tongue image of Traditional Chinese Medicine in patients with different risk stages of chronic atrophic gastritis. Shanxi Zhong Yi 2025; 46: 756-60.
19. Sanyal AJ, Brunt EM, Kleiner DE, et al. Endpoints and clinical trial design for nonalcoholic steatohepatitis. Hepatology 2011; 54: 344-53.
20. Brunt EM. Nonalcoholic steatohepatitis. Semin Liver Dis 2004; 24: 3-20.
21. Vali Y, Lee J, Boursier J, et al. Biomarkers for staging fibrosis and non-alcoholic steatohepatitis in non-alcoholic fatty liver disease (the LITMUS project): a comparative diagnostic accuracy study. Lancet Gastroenterol Hepatol 2023; 8: 714-25.
22. Harrison SA, Ratziu V, Boursier J, et al. A blood-based biomarker panel (NIS4) for non-invasive diagnosis of non-alcoholic steatohepatitis and liver fibrosis: a prospective derivation and global validation study. Lancet Gastroenterol Hepatol 2020; 5: 970-85.
23. Pavlides M, Mózes FE, Akhtar S, et al. Liver Investigation: Testing Marker Utility in Steatohepatitis (LITMUS): assessment & validation of imaging modality performance across the NAFLD spectrum in a prospectively recruited cohort study (the LITMUS imaging study): study protocol. Contemp Clin Trials 2023; 134: 107352.
24. Wong VW, Chu WC, Wong GL, et al. Prevalence of non-alcoholic fatty liver disease and advanced fibrosis in Hong Kong Chinese: a population study using proton-magnetic resonance spectroscopy and transient elastography. Gut 2012; 61: 409-15.
25. Tamaki N, Ajmera V, Loomba R. Non-invasive methods for imaging hepatic steatosis and their clinical importance in NAFLD. Nat Rev Endocrinol 2022; 18: 55-66.
26. Castera L, Friedrich-Rust M, Loomba R. Noninvasive assessment of liver disease in patients with nonalcoholic fatty liver disease. Gastroenterology 2019; 156: 1264-81.e1264.
27. Friedman SL, Neuschwander-Tetri BA, Rinella M, Sanyal AJ. Mechanisms of NAFLD development and therapeutic strategies. Nature Medicine 2018; 24: 908-22.
28. Stefan N, Schick F, Birkenfeld AL, H?ring HU, White MF. The role of hepatokines in NAFLD. Cell Metab 2023; 35: 236-52.
29. Pal D, Dasgupta S, Kundu R, et al. Fetuin-A acts as an endogenous ligand of TLR4 to promote lipid-induced insulin resistance. Nat Med 2012; 18: 1279-85.
30. Conklin D, Gilbertson D, Taft DW, et al. Identification of a mammalian angiopoietin-related protein expressed specifically in liver. Genomics 1999; 62: 477-82.
31. Geng L, Lam KSL, Xu A. The therapeutic potential of FGF 21 in metabolic diseases: from bench to clinic. Nat Rev Endocrinol 2020; 16: 654-67.
32. Selva DM, Hogeveen KN, Innis SM, Hammond GL. Monosaccharide-induced lipogenesis regulates the human hepatic sex hormone-binding globulin gene. J Clin Invest 2007; 117: 3979-87.
33. Misu H, Takamura T, Takayama H, et al. A liver-derived secretory protein, selenoprotein P, causes insulin resistance. Cell Metab 2010; 12: 483-95.
34. Ye D, Wang Y, Li H, et al. Fibroblast growth factor 21 protects against acetaminophen-induced hepatotoxicity by potentiating peroxisome proliferator-activated receptor coactivator protein-1α-mediated antioxidant capacity in mice. Hepatology 2014; 60: 977-89.
35. Pan X, Shao Y, Wu F, et al. FGF 21 Prevents angiotensin Ⅱ-induced hypertension and vascular dysfunction by activation of ACE2/angiotensin-(1-7) axis in mice. Cell Metab 2018; 27: 1323-37.e1325.
36. Tilg H, Ianiro G, Gasbarrini A, et al. Adipokines: masterminds of metabolic inflammation. Nat Rev Immunol 2025; 25: 250-65.
37. Zhao S, Kusminski CM, Scherer PE. Adiponectin, leptin and cardiovascular disorders. Circ Res 2021; 128: 136-49.
38. He C, Liao Q, Fu P, et al. Microbiological characteristics of different tongue coatings in adults. BMC Microbiol 2022; 22: 214.
39. Yang C, Gai X, Zheng YX, et al. Study on tongue coating microbes of bitter taste, sticky and greasy taste in chronic atrophic gastritis. J Tradit Chin Med 2023; 43: 160-7.
40. Ferguson D, Finck BN. Emerging therapeutic approaches for the treatment of NAFLD and type 2 diabetes mellitus. Nat Rev Endocrinol 2021; 17: 484-95.
41. Yuan L, Yang L, Zhang S, et al. Development of a tongue image-based machine learning tool for the diagnosis of gastric cancer: a prospective multicentre clinical cohort study. EClinicalMedicine 2023; 57: 101834.
42. Chen Y, Yin M, Fan L, et al. Mirror-like tongue is an important predictor of acute heart failure: a cohort study of acute heart failure in Chinese patients. J Tradit Chin Med 2023; 43: 1243-51.
43. Liu Y, Fan L, Zhao M, et al. Study on a Traditional Chinese Medicine constitution recognition model using tongue image characteristics and deep learning: a prospective dual-center investigation. Chin Med 2025; 20: 84.
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