Journal of Acuherb in Medicine


Diabetes Mellitus

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Diabetes Mellitus 

 

Huang Di Hei Jing (The Yellow Emperor’s classic of Internal Medicine) is the earliest TCM theoretic book. It is divided into two partsSuwen (The Book of plain Questions) andLingshu (The Book of Miraculous Pivot)

In ancient China, the word “diabetes” did not exist. However, an early definition of the illness can be found in the medical classicHuang Di Nei Jing (The Yellow Emperor’s Classic of Internal Medicine) written during the Han Dynasty (approx. 200 BC). Under this book’s Suwen (The Book of Plain Questions)section, diabetes was defined by the following symptoms “xiao ke” and “fei xiao,” which translate into excessive drinking, and “ge xiao” and “xiao zhong,” which mean excessive eating. According to the Suwen, additional clues to the disease include excreting large amounts of urine with sugar in it and weight loss. The ancient Chinese people also thought it was caused by improper diet and mainly affected the upper class. The Book of Plain Questions describes the diabetes sufferer as follows: ” When, a person has eaten too much greasy and sweet food, the body produces dry-heat evils which causes qi to stay in the middle-burner of the body until finally the qi flows upward and spills over resulting in diabetes.” The “Efficacious Formulae Recorded from Antiquity to the Present,” penned by medical practitioner Zhen, Li-yan during the Sui Dynasty (589~618 AD), wrote that diabetes patients usually suffer from the following symptoms: “Frequent thirst that leads to excessive drinking, excessive urination, and urine that is sweet and without fat.”

Diabetes is generally attributed to a deficiency of body fluids and the excessive accumulation of dry or heat evils inside the body. Dry and heat evils come from external environmental sources such as an improper diet and are transformed internally into disease causing factors such as a kidney yin deficiency. Dry and heat evils trigger certain organs in the body to react negatively. The organs that are most affected are the lung, stomach and kidney.

The Lungs: The lungs are responsible for the transformation and movement of water in the body. Dry-heat hurts the lungs and causes body fluid to flow straight down freely without being distributed to the rest of the body. This results in frequency in urination, thirst and excessive drinking, which are all symptoms of diabetes.
The Stomach: The stomach is a reservoir for food and drink. An intense stomach fire is caused by dry-heat which damages the stomach. As a result, the metabolic rate rises and triggers an increase in appetite and constipation. An increase in appetite is also another hallmark symptom of diabetes.
The Kidneys: Since the kidneys control water metabolism, deficiency of the kidney-yin and “virtual fire”(the heat developed inside the body by a relative excess of yang) creates dry and heat evils. This damages the “vaporization” function and results in the kidneys’ failure to separate turbid water, which will be turned into urine and clean water, which is reused by the body. It also affects the opening and closing of the bladder. The end result is an excessive amount of urine, urinary frequency and the production of urine with traces of sugar.

Understanding water metabolism from a TCM perspective

In western medicine diabetes mellitus is a metabolic disorder that occurs when there is a chronically high level of glucose (sugar) in the blood caused by a deficiency or complete lack of insulin. The insulin deficiency and high glucose levels cause serious damage to the body over time if left untreated and in severe cases may cause death.

This western understanding of diabetes is not present in TCM. Its diagnosis is based on the clinical symptoms of diabetes such as excessive thirst, hunger and urination, which may or may not be accompanied by sudden weight loss. Depending on each individual’s symptoms, it is further classified into four types of disharmony patterns discussed in the diagnosis section. Even though two people may be diagnosed with diabetes from a western perspective, these individuals may present with two different disharmony types from a TCM perspective and thus will be treated differently. 

Causes

The primary causes of diabetes are detailed below. 

1. Congenital Deficiency
  Individuals born with a congenital deficiency are genetically susceptible to this disease. Dysfunction of the lungs and kidneys affects the water metabolism in the same way dysfunction of the spleen and stomach affects digestive power. In turn, these organs cannot function properly and diabetes is caused by the mechanisms listed in the definition section.
2. Improper Diet
  Over consumption of greasy food and alcohol drinks may impair the stomach and the spleen, which in turn fail to transform and transport these substances into nutrition for the body. The undigested food then accumulates and transforms into heat and dryness evils, and consumes the body fluid, which causes thirst and excessive drinking.
3. Emotional Disorders
  Over stimulation of emotions may spark stagnation of vital qi and then transform it into a heat-evil, which consumes the yin-fluid of organs like the lungs and stomach. Symptoms of diabetes occur when the body’s metabolism becomes unbalanced from dysfunction of the lungs and spleen.
4. Tension
  Overwork leads to consumption of yin-essence in the kidneys and produces internal fire or heat evils. This accelerates the depletion the nutrients and triggers a rise in metabolic rates, which results in increased appetite but with weight loss. An increased appetite and weight loss are some of the classic symptoms of diabetes.
5. Pleasure Indulgences
  Excessive sexual activity can cause consumption of kidney essence (a yin-component that includes sperm and egg cells and blood), which leads to a relative excess of yang. When this occurs, a “virtual fire” or a heat evil is created which heats up the lungs and stomach causing organ damage. In turn, these organs cannot function properly and diabetes is caused by the mechanisms listed in the definition section.
6. Drugs
  Improperly used libido drugs can cause heat evils to accumulate in the lower-burner. When individuals consume them for a long time and get older, the kidney yin will become insufficient and cause damage to the kidneys’ “vaporization” function. See definition section. The damage of this function is one of the causes of diabetes.

Symptoms

TCM practitioners recognize symptoms of diabetes from both a western and eastern point of view.

Clinical distinction in western medicine: Type I diabetes occurs in individuals who do not produce any insulin. The onset of Type I diabetes begins at a young age. Clinical symptoms change quickly and become increasingly more serious. Typical signs include excessive and constant thirst, excessive drinking and eating, excreting an excessive amount of urine with sugar in it, and weight loss. 

Type II diabetes occurs in individuals who do not have enough insulin or whose insulin does not work properly. The onset of Type II diabetes usually begins in middle or old age. However, the disease may be present in a sub clinical form for years before diagnosis. The main symptoms are extreme fatigue, dry mouth and excessive thirst. Other symptoms like excessive urination, and excessive eating may not be as obvious with this type. 

According to Traditional Chinese Medicine diagnosis, the disease can be divided into four types of disharmony patterns: 

1. Yin Deficiency and Excessive Heat Type
Symptoms related to this type include thirst for cold drinks, an increased appetite, and dislike of heat and emotional imbalances. Other symptoms include dark urine, constipation, an appearance of a red tongue with a yellow coating and a pulse that feels rapid and taut or slippery.
2. Deficiency of Qi and Yin Type
Symptoms include shortness of breath, heart palpitations, fatigue and weakness that can lead to reluctance to speak. Additional symptoms include: constant thirst, spontaneous sweating, sweating during sleep, being easily irritable, having trouble sleeping, feeling heat in the palms of the hands and soles of the feet, dark urine and constipation. The tongue appears dry, red and swollen, while the coating is scaled off. The pulse is weak and uneven.
3. Blood Stasis and Internal Obstructed Type 
Symptoms include darkened skin, weight loss and malaise, fullness and blurred pain in the chest, numbness or stabbing pain in limbs, which worsens at night. People who suffer from this form of diabetes will also have purple-colored lips, and a tongue that is dark in color or appears bruised. The tongue will also be covered with a thin white or yellow colored coating, or appear dark and bruised. The pulse feels taut or uneven.
4. Deficiency of Yin and YangType Symptoms include a below normal body temperature, aversion to coldness with cold feeling limbs, a pale face, ringing in the ears, weakness in the lower back, occasional fever, sweating at night, impotence or premature ejaculation of sperm. The stool is loose and excessive clear urine is passed. The bulging tongue appears light pink, and is blanketed with a thin white coating or a white greasy fur. The pulse is faint or rapid and uneven.

Other related patterns: 
Accumulated Internal Wet Heat Type: The body appears fat and bloated. The mouth is dry and has a bitter taste with foul smelling burps. Other symptoms include itchy skin, yellow and cloudy urine, and loose stool. The tongue appears swollen and is covered with a yellow greasy or turbid yellow greasy fur coating. The pulse feels weak and slippery. 

Diagnosis

TCM practitioners will diagnosis diabetes according to its clinical symptoms and further characterize it by the disharmony pattern an individual displays.

Diabetes, as is commonly understood from a western medicine perspective, is largely dependent on western methodologies for diagnosis. (See western medicine diagnosis section.)

TCM Examination Techniques:

Diagnosis in TCM is based on four examination techniques. The first is “questioning.” The TCM practitioner will want to know what the individual’s current complaints are, and their family’s medical history. The second technique is “observation.” Physical features of the body such as the face, tongue, hair, nails, sputum (mucus that is coughed up) and examining the area of pain all offer clues to the problem. The tongue is particularly useful gage to assess illness because it is seen as a window to look at the functioning of internal organs. The third technique is “hearing and smelling.” Smelling the sputum and breath and listening to the sounds coming from the chest offer additional clues. The last technique used in examination is “touching.” Feeling the pulse is a cornerstone of TCM diagnosis and gives the TCM practitioner a lot of information about the body’s imbalance. 

In TCM theory, diabetes is characterized by a combination of symptoms below:

Excessive eating
Excessive drinking
Excessive urine
Wasting of body tissues or weight loss

Note: If a TCM practitioner suspects there might be a serious problem that Chinese medicine alone cannot treat, he or she will recommend the individual see a western doctor for further follow up. When an individual experiences severe symptoms like those listed above, it should be taken very seriously, and the appropriate medical care should be sought out preferably in an emergency setting. 

The four Types of Disharmony Patterns Even though diabetes can be diagnosed from the above symptoms, the information gathered from the TCM physical examination is used to determine which type of disharmony pattern an individual has. This is important because at the various stages of a disease, a varicty of disharmony patterns are present which require different types of therapy. This is the reason two individuals with the same disease may be treated very differently by their TCM practitioner. 

1. Yin Deficiency and Heat Excessive Type
  In TCM, yin deficiency commonly refers to a deficiency of yin fluids such as blood and body fluids. Without sufficient nourishment by these fluids, excitatory functions (heat excessive manifestations) become dominant and lead to symptoms of fever, thirst or increased appetite.
2. Deficiency of Qi and Yin Type
  Qi can be interpreted as the “life energy” or “life force,” that flows within us. Deficiencies in qi and yin result in organ dysfunction. In diabetes, the most affected organs are the lungs, stomach and kidneys.
3. Blood Stasis and Internal Obstructed Type
  This refers to a state where the blood cannot circulate smoothly, and is usually accompanied by qi stagnation. The organs lose nutrients from the blood, which cause symptoms like numbness in the limbs or localized tissue death. For example, people with diabetes may suffer from ulcerations in their legs and feet due to poor blood supply.
4. Deficiency of Yin and Yang Type
  The body’s physiological functions (yang) and physical forms (yin) are maintained in constant balance to achieve health. When vital qi is severely deficient for a long time, this type will develop. It is a more general type of deficiency that can occur in many diseases such as diabetes.

Other Related Disharmony Patterns: Accumulated Internal Wet Heat Type Improper diet is one of the causes of diabetes from a TCM perspective. This impairs the proper functioning of the spleen and stomach, which leads to formation of wet and heat evils. These evils affect the fluid metabolism inside the body, and diabetes symptoms like excessive thirst and hunger can appear. 

Diabetes should be differentiated from hyperthyroidism (over-functioning of the thyroid gland)

Sometimes it is difficult to distinguish diabetes from hyperthyroidism since both share similar symptoms. In both conditions there may be the presence of an increased appetite associated with weight loss. Diabetes patients are frequently thirsty, and excrete an excessive amount urine with glucose (sugar) present in it. However, people suffering from hyperthyroidism experience irritability, excrete loose yellow stools, and have eyelid retraction and eyeball protrusion. Individuals with this condition may also suffer from a rapid and forceful heartbeat, and swelling of the thyroid gland in the neck. To safely make the distinction, laboratory examinations of the blood and urine can be done to diagnose these two conditions.

Treatment

Even in ancient times, TCM practitioners knew diabetes was a serious life threatening disease if not treated properly. Below lists some of the prescription examples used to treat the different disharmony patterns that occur in diabetes. 

Yin Deficiency and Heat Excessive Type


Therapeutic aim:
Clears away heat and dry evils, nourishes yin to promote the production of body fluid

Prescription: 
Individuals with minor cases:
Xiaoke Fang

Huang lian golden thread
Gau lou gen snakegourd root
Sheng di huang zhi juice of fresh rehmannia root
Hua fen pollen
Ou zhi Juice of fresh lotus root
Ren ru human milk

Individuals with severe cases: 
Wu zhi yu quan pill 

Huang lian golden thread
Zhi mu common anemarrhena root
Wu mei dark plum
Gan cai liquorice root
Ren shen ginseng
Mai dong dwarf lilyturf tuber
Wu wi zi Chinese magnolia vine fruit
Di huang rehmannia root
Dang gui Chinese angelica
Hua fen pollen
Ge gen kudzu vine root
Lian rou lotus rhizome node
Ren ru human milk
Niu ru milk
Zhe zhi juice of Sugar cane
Li zhi pear juice
Ou zhi juice of fresh lotus root

 

Deficiency of Qi and Yin Type


Therapeutic aim:
Invigorates qi and nourishes yin 

Prescription: 
Individuals with minor cases:
Huang qi decoction 

Huang qi milkvetch root
Fu ling Indian bread
Mai dong dwarf lilyturf tuber
Di huang rehmannia root
Tian hua fen snakegourd root
Wu wi zi Chinese magnolia vine fruit
Gan cao liquorice root

Individuals with severe cases:
Di huang drink 

Ren shen ginseng
Huang qi milkvetch root
Tian mai dong cochin Chinese asparagus root
Shi hu dendrobium
Pi pa ye loquate leaf
Ze xie oriental water plantain root
Zhi qiao orange fruit
Sheng shu di rehmannia root (processed & unprocessed)

 

Blood Stasis and Internal Obstructed Type

Therapeutic aim:Invigorates qi, enriches the blood and removes obstruction in the meridian channels 

Prescription: 
Bu yang hai wu decoction 

Huang qi milkvetch root
Gui wei tail part of Chinese angelica root
Chis hao red peony root
Tao ren peach kernel
Hong hua safflower
Di long earthworm
Chuan xiong Szechwan lovage root

 

Deficiency of Yin and Yang Type

Therapeutic aim:Nourishes yin and warms yang

Prescription:
Lu rong pill 

Huang qi milkvetch root
Ren shen ginseng
Mai dong dwarf lilyturf tuber
Wu wi zi Chinese magnolia vine fruit
Xuan shen figwort root
Shu di processed rehmannia root
Yu ru dogwood fruit
Lu rong hairy antlers of young stag
Po gu zhi malaytea scurfpea fruit
Ru cong rong desert living cistanche
Di gu pi Chinese wolfberry root-bark
Fu ling Indian bread
Huai hiu xi achyranthes root

Western Medicine Treatment

1. Pharmacological Therapy:

Type 1 Diabetes
Insulin is the mainstay therapy for patients with type 1 disease. Most patients are on human insulins, which are synthesized by recombinant DNA technology. Beef (no longer available in the U.S.) and pork insulins are less preferred due to potential of antigenic (allergic) reactions such as itching and skin reactions at the injection sites. Of the available insulins, some are rapid acting, or short acting, which are used mainly before each meal. Others are intermediate acting, or long acting, which are injected once or twice daily under the skin. Table 1 is a summary of the onsets of action, duration of action and other characteristics of the various insulins available (in the United States). 


Type /Name Onset
(hour)
Peak
(hour)
Duration
(hour)
Appearance
Lispro 10 – 15 mins. 30 – 90 mins. <=5 Clear
Aspart 15 mins. 45 – 90 mins.> 3 – 5 Clear
Regular 1/2 – 1 2 – 4 5 – 7 Clear
NPH/Lente 1 – 3 6 – 14 24 + Cloudy
Ultralente 4 – 10 8 – 20 18 – 28 Cloudy
Glargine 5 no peak 24 + Clear
NPH70/Reg 30 1/2 2 – 12 +/- 24 Cloudy
NPH50/Reg 50 na na +/- 24 Cloudy



Type 2 Diabetes
Of the proposed pathology of type 2 diabetes (see figure 1), there are now different oral pharmacological agents to target the specific defects: there are three categories of agents, the insulin secretagogues, inhibitors of glucose breakdown, and the insulin sensitizers. The insulin secretagogues include sulfonylureas and metiglinides, which are used to stimulate more insulin secretion. Alpha-glucosidase inhibitors delay the absorption of glucose and are usually used to control post-meal hyperglycemia. The insulin sensitizers include biguanides and thiazolidinediones, which can help the available insulin to be taken up more effectively. Table 2 lists the different agents with their sites and mechanisms of actions.

Click here to see the Table 2 Pharmacologic Classes to Control Hyperglycemia in Type 2 Diabetes

The selection of agents for a patient with type 2 disease will depend on the degree of hyperglycemia, particular defects, as well as other contraindications that may be present. Table 3 lists the agents according to their relative potency, other non-glycemic effects and adverse effects. 

Click here to see the Table 3 Relative Efficacy and Adverse Effects of the Oral Agents Used in Type 2 Diabetes

If we look at the patient according to the natural progression of diabetes, oral agents can also be picked according to the severity of disease. (See table 2) For example, an alpha glucosidase inhibitor or metiglinide may be most appropriate for someone who has mildly elevated glucose level after eating a meal. As this patient becomes less controlled with higher glucose and elevated fasting levels, we may then consider sulfonylureas, biguanides, or thiazolidinediones, all of which are considered more potent agents. There will be patients who may have multiple defects in the pathogenesis of their disease, therefore, will require a combination of agents (with different mechanisms of action) in order to control their diabetes. This can include the combination of different oral agents as well as combination of oral agents and insulins. Metformin can be particularly useful among patients who have concurrent problems with weight, cholesterol and triglycerides because it can also improve these indices. Concerns with the use of these oral agents lie in the side effects they can cause. Therefore, frequent and regular monitoring of patients is necessary to avoid hypoglycemia while they are on sulfonylureas, and to avoid stomach gas and diarrhea while they are on metformin. Metformin is also associated with a rare problem of lactic acidosis when it’s accumulated in the body with deterioration of kidney function. Gastrointestinal gas and diarrhea are often causes of therapy discontinuation in patients taking acarbose and miglitol. The thiazolidinediones are also associated with rare liver toxicities and need frequent monitoring of the liver enzymes.

2. Therapeutic Approach:

It’s recommended that the first stage of therapy for diabetes should include diet and exercise. An average size adult patient with diabetes should receive approximately 2000 calories per day with 60% carbohydrate, 20% protein, and 20% fat. However, calories or fat should be more restricted if the patient is overweight or has abnormal cholesterol / triglycerides; carbohydrate limited if glucose is uncontrolled; and protein also restricted if the patient has kidney complications from diabetes. Exercise should be incorporated into the therapeutic program (with doctor’s approval and supervision) because it will enhance the body’s sensitivity to insulin and increase utilization of glucose. Diet and exercise should be encouraged in all patients with diabetes and should remain a component of the therapeutic program as long as patients are compliant and gain benefits. Unfortunately, there are many patients who are not willing to diet or physically unable to exercise, and therefore should receive medications to aggressively control glucose early on during their disease.

Type 1 Diabetes
In a patient with newly diagnosed type 1diabetes, clinicians often start with a simple schedule of insulins. To improve glucose control, doses of the insulin(s) and / or the schedule may have to be adjusted often and on an as-needed basis. A typical regimen to start with includes intermediate- or long-acting insulin once or twice daily with short- or rapid-acting insulin before meals. However, patients with type 1 disease often have big fluctuations of glucose levels and suffer from extreme hyperglycemia or hypoglycemia. Therefore, tighter control is often necessary. Until recently, changing the timing of insulin injections and the dosage of different insulins were all that could be done to maximize glycemic control in type 1 patients. Over the last two years, however, rapid acting insulins have been made available, which made the control of glucose more precise. (See table 1) Instead of injecting the short-acting regular insulin about 30 minutes before meals, patients can inject the new rapid-acting insulins (lispro, aspart) within 15 minutes before meals. In addition, the newly available basal insulin glargine will make the control of glucose more consistent due to its slow release profile, which acts similarly to the physiological pattern of insulin release in our body. 

Before injecting insulin, tap the syringe to rid it of any air bubbles.
Prick the skin and underlying fatty tissue to avoid injecting into an artery or vein.


Type 2 Diabetes 
Due to the recent differentiation in the pathogenesis of type 2 diabetes, there have been changes in the way we manage the disease. As previously mentioned, type 1 patients have an absolute lack of insulin and require insulin injections; type 2 patients have a relative lack of insulin, either due to insensitivity to insulin or an insulin receptor defect, improper timing of insulin secretion, abnormal glucose production, or a combination of these factors. In patients with type 2 diabetes, herapeutic approaches should target the specific defect(s) in each patient. A proposed algorithm based on the level of glycemic control is described as following: 

Nutritional therapy / Exercise program x 3 month trial
If inadequate response or therapeutic goal is not met.
 
Add oral monotherapy x 4-12 weeks, titrate to maximum tolerable dose
If inadequate response or therapeutic goal is not met.
 
Add second oral agent x 4-12 weeks, titrate to maximum tolerable dose
If inadequate response or therapeutic goal is not met….
 
Add Oral agent(s) + insulin 
OR Insulin therapy alone 
OR Oral agent(s) day + insulin at bedtime

Prevention

Eat a balanced diet. 
The Book of Plain Questions orSuwen (approx. 200 BC) says: “Cereal is the foundation of the basic diet, meat provides protein and fat which is very useful, fruits can promote the digestion of food, and vegetables provide suitable supplements.” This ancient diet recommendation matches the modern day dietary management of diabetes, which is to eat a balanced diet with low sugar and fat intake.
   
Exercise regularly. 
A nutritious diet and adequate exercise play important roles in diabetes. Daily exercise should be encouraged in order to promote the utilization of glucose (sugar) by the body tissues and decrease the body’s insulin requirement.
   
Live a balanced life. 
Long hours at work and a stressful and fast-paced environment can make people more susceptible to illness. As a result living a balanced life mixed with both work and pleasure can help the brain and body to stay healthy and may help to lessen the severity of the diabetes or prevent diabetes onset.
   
Be aware of family medical history and conditions that increase the risk of getting diabetes.
Individuals with a history of diabetes, high blood pressure and obesity in their family should be aware that these conditions could predispose them to getting diabetes. Additionally, individuals who already have risk factors such as high blood pressure and who are obese should regularly have their blood sugar level checked by their doctor to make sure they have not developed the disease.

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