Hamidreza Sheikh Roshandel,Roksana Mirkazemi,Maryam Monfared,Hossein Kheirandish,Mehdi Vali Nejad,Fatemeh Ghadimi,Maryam Ladani Nejad

1College of Traditional Medicine of Armenia,Tehran,Iran.Azad University of Alternative Medicine,Tehran,Iran.2Managing Director and Founder Farzanegan Nik Andish institute for the development of knowledge and technology,Tehran,Iran.3Islamic Azad University of Medical Sciences of Tehran,Department of Traditional Medicine,Tehran,Iran.4Iran Cupping Research Institute,Tehran,Iran.5Research Institute of Nutritional Sciences and Traditional Medicine Ta'm Asrar,Tehran,Iran.

Abstract In traditional Iranian medicine,accurate determination of Mizaj plays a very important role in the etiology and treatment of diseases.There are a lot of evidences and documents in original Iranian traditional medicine books and documents related to the relationship between Mizaj and the facial character and appearance.In this study,we investigated the validity of determining Mizaj based on facial dimensions and characteristics.For this purpose,a software was developed to determine Mizaj based on an algorithm of facial dimensions and appearance.This cross-sectional study investigated the validity of identifying Mizaj based on facial dimensions and appearance(using the facial-based Mizaj recognition software)by comparison with the Mizaj determined by a standardized questionnaire and by using the traditional method of experts’ opinion on determining the Mizaj.The inclusion criteria of the study were being healthy,using no medication,and consent to participate in the study.The sample size of the study was 83 people.For analyzing the data,SPSS software version 19 was used.Also,for examining the level of internal agreement of the data,Kappa statistics were used.The results of the study showed that the level of agreement between determining Mizaj by facial characteristics with the experts’distinction of Mizaj is almost complete,and the level of agreement with the Mizaj questionnaire was moderate.The results showed that the facial-based Mizaj recognition software has a good validity to detect the Mizaj of individuals in the study sample.Although,studies with a larger sample size are needed to confirm the results of this study.

Key words:Kappa,Mizaj,Temperament,Traditional medicine,Validity

Background

In traditional Iranian medicine,Mizaj is defined as a quality that results from the combination of different amounts and unequal proportions of the four elements that a body is made of(soil,fire,water,and air).The elements break down into very small particles; and when these particles interact with each other,they create a new quality that enfolds all the particles of the elements.As these elements have four qualities(warm,cold,dry,and wet),so the Mizaj of the newly formed or decomposed body is also a product of these four qualities[1].

The experts of traditional medicine use different characteristics to identify the Mizaj of individuals such as,the amount of body muscle and fat,characteristics of hair,skin color,the shape of body limbs,amount of sleep and awake time,individual actions(such as growth rate,hair growth rate,tooth growth rate,speaking speed,speech continuity,etc.),body waste disposal,personality characteristics(such as paying attention to moods like cleverness,shamelessness,daydreaming,optimism,laziness,etc.).

Mizaj has two types,innate Mizaj and acquired Mizaj.Innate Mizaj is the Mizaj that people are born with it.The other is acquired Mizaj,which is acquired due to difficulties,illnesses,etc.,during a lifetime [2].Although there is a belief that there are as many different Mizaj as the number of people in the world[2,3].Generally,Mizaj is classified into 4 types of simple and 4 types of compound Mizajs.Simple Mizaj includes warm,cold,wet,and dry Mizajs,and compound Mizaj includes warm and dry,warm and wet,cold and dry,and cold and wet Mizajs[2–7].

In traditional Iranian medicine,the condition of health and etiology of diseases are associated with the moderation of the human Mizaj.Therefore,accurate determination of the Mizaj plays a very important role in the etiology and treatment of diseases [8–10].Up to now,Mizaj recognition has been done by scholars and scientists of traditional medicine based on traditional methods and its knowledge has been passed from generation to generation by the traditional books and physicians.However,providing new technologies and standard methods to determine Mizaj,is crucial for enhancing the use of traditional medicine in the modern age.

The use of facial characteristics and appearance to recognize Mizaj were mentioned in the traditional medicine texts and documents[3,11,12].According to the books of traditional medicines,the overall characteristics of the face like the size of the forehead,the ratio of the eyes to the face,the color of the pupil,and the composition of the sclera of the eye,the size and shape of the noise and the shape of the cheeks,etc.determine the Mizaj of individuals.For example,large eyes,which extend across the face,are a sign of wet Mizaj.A narrow nose with a beautiful sharp point is a sign of dry Mizaj.A wide nose,fleshy cheeks,a little facial hair,and a firm tongue indicate that the Mizaj is wet12.Lip shape,mouth shape and structure,mouth-to-face ratio,tongue size,chin shape,lip color also,have an important role in recognizing Mizaj of individuals[3,11,12].

In order to determine the accuracy and validity of determining Mizaj using facial characteristics and appearance,a software for the Mizaj recognition was developed that determines the Mizaj based on the algorithm of the proportion of facial characteristics like size of eyes or nose to forehead or lip sizes.Also,this software uses the general structure of the face,the size of the facial components,neck,and shoulders to determine the Mizaj.In this software,people's innate Mizaj are numerically interpreted and measured.Therefore,this study was conducted to investigate the level of validity and accuracy of determining Mizaj based on facial dimensions and appearance(by using facial-based Mizaj recognition software)by comparing the results with a standard questionnaire for determining Mizaj [13],and by using the traditional method of experts’opinion on determining the Mizaj.

Methods

In this cross-sectional study,Mizaj was determined by three different methods including administration of a standard questionnaire [13],using facial dimensions and appearance(by using facial-based Mizaj recognition software),and the opinion of experts in this field.The sample size of the study was 83 individuals.The inclusion criteria of the study were being healthy,not being under any medications,and consent to participate in the study.The location of this study was the “Ta'm Asrar Nutritional Sciences and Traditional Medicine Research Institute”.Sampling was done from April to May 2019.

Individuals referred to “Ta'm Asrar Nutritional Sciences and Traditional Medicine Research Institute”,who were eligible based on the inclusion criteria were included in the study.In the first stage of the study,the Roshandel questionnaire was used as one of the ways to determine the Mizaj.This questionnaire has 26 items,its validity was confirmed by 5 experts in traditional medicine,its reliability was confirmed by using Cronbach's alpha index of 0.852,and the value of inter-cluster correlation for all types of Mizajs was complete(100%)[13].In this questionnaire,the color of skin,the color of head hair in adolescence or childhood,facial structure,forehead size,eyes to face ratio,iris color,color and condition of the sclera,nose size and shape,lips,mouth,and cheeks and their ratio to face,the shape of the chin,the length of the tongue,the length of the neck,the condition of the arteries,the shape of the shoulder muscles,and the length and the diameter of the shoulder are used to determine the Mizaj[13].

In the second stage of the study,the Mizaj was determined based on facial characteristics and appearance by using facial-based Mizaj recognition software.This software determined the Mizaj based on the photo of the face,which was taken in a standard situation.In the last stage,each participant was visited by 3 Mizaj experts at the institute on three different days,and the experts determined their Mizaj based on their knowledge.In some cases,the opinions of all three experts on determining the Mizaj of a person were the same.The opinions of the two experts were considered as the Mizaj of the person if the opinion was not the same for all the three experts.

Data analysis

Data analysis was done by using SPSS software version 19.Descriptive statistics including mean,standard deviation,frequency,and percentage were used to analyze the data.Also,Cohen Kappa statistics measures were used to examine the agreement level of the data from three different methods.A Kappa coefficient is a number between -1 and +1,and whenever it is closer to +1,indicates a higher level of agreement.When it is closer to -1,it indicates an inverse agreement,and when it is closer to zero,it indicates disagreement.Kappa coefficient,between 0–0.20 indicates disagreement,between 0.21–0.39 indicates minimum agreement,0.40–0.59 indicates weak agreement,0.60–0.79 indicates moderate agreement,0.80–0.90 indicates high agreement,and more than 0.90 indicates complete agreement.

The Kappa coefficient was used to determine the level of agreement between determined Mizaj by each expert’s opinion,combined experts’ opinion,using questionnaire and using facial characteristics.

Results

The study participants included 48 females(57.8%)and 35 males(42.2%),with a mean age of 32.8 years old(and range 11 to 68 years).35 of the participants(42.2%)were between 17 and 30 years old,35(42.2%)were between 30 and 40 years old,and 13(15.6%)were over 40 years old.Only 13 patients(15.7%)had a normal body mass index,26 patients(31.3%)were obese,and 1 patient(1.2%)was underweight(Table 1).The results of the Kappa coefficient showed that there was a high level of agreement between experts 1 and 2,a moderate agreement between experts 1 and 3,and an almost complete agreement between experts 2 and 3.If two or more experts diagnosed the same Mizaj for each person,that Mizaj was listed as the general opinion of the experts(Table 2).

The general opinion of the experts with the facial-based Mizaj recognition software had an almost complete agreement,and the general opinion of the experts with the Mizaj questionnaire had a moderate agreement.The level of agreement between facial-based Mizaj recognition software with expert number 1 showed a high level of agreement and with experts 2 and 3 showed almost complete agreement(Table 2).

The agreement level for the Mizaj questionnaire with 3 experts and with facial-based Mizaj recognition software was moderate(Table 2).

Table 1 Participants characteristics

Table 2 Agreement level of experts’ opinion and general opinion,with facial-based Mizaj recognition software and questionnaire

Discussion

This study was conducted to investigate the validity of determining Mizaj recognition based on facial characteristics and appearance,with Mizaj recognition using a questionnaire,and Mizaj recognition done by experts in this field.As in traditional Iranian medicine,the definition of health and disease is associated with the moderation of human Mizaj,knowing the Mizaj plays a very important role in the etiology and treatment of diseases [8–10].Yet,the most reliable source for determining Mizaj of individuals was the opinion of experts in this field.However,this method of determining Mizaj could be subject to bias depends on the level of expertise and experience of the expert.Hence,identifying new methods with a lower chance of bias like using facial-based Mizaj recognition software seems necessary.

There are some previous studies that attempted to develop a more objective and reliable method for determining Mizaj.In the year 2014,Mojahedi et al.developed a self-assessment questionnaire and examined its validity and reliability.The results showed that the questionnaire has good reliability and can differentiate between different Mizajs [14].Also,in the year 2015,Roshandel et al.designed and standardized a structural questionnaire to determine the Mizaj.The findings of their study showed that the designed questionnaire had acceptable validity and reliability [13].Despite the validity and reliability of this questionnaire,this study showed that there is a moderate agreement between the results of the Facial-based Mizaj recognition software and the Mizaj questionnaire.The moderate agreement between the Facial-based Mizaj recognition software and the questionnaire can be due to the reason that the questionnaire is filled in by individuals and is self-declared,which can be biased by cognitive bias,individual perception,and memory errors.

Also,this study showed that the level of agreement between two out of three experts in this study with the facial-based Mizaj recognition software was almost complete,but it was high with the third expert’s opinion.Also,the level of agreement between the three experts’ opinions was not complete.This shows the importance of the high skill and experience of experts’diagnosis in determining Mizaj.Also,the general opinion of the experts with the face-based Mizaj recognition system was in complete agreement,which shows the reliability of Mizaj determining results by the Facial-based Mizaj recognition software.

Since the level of agreement between the experts’opinion and the facial-based Mizaj recognition software was higher than the level of agreement between the experts’opinion and questionnaire,the use of the facial-based Mizaj recognition software seems even more reliable than the questionnaire.

Conclusion

Based on this research,it can be concluded that determining Mizaj using facial characteristics has a good validity in the study’s sample.However,to replace it with the opinion of experts or a questionnaire,it needs to be studied on a larger scale and with a larger sample size study.Also,conducting similar studies among people of different races and nationalities,and modifying and reviewing the system algorithm based on the results of studies on different races and nationalities can facilitate the use of this method of Mizaj recognition,at the international level.