Traditional Chinese Medicine in the Treatment of Diabetes

In Brief

Traditional Chinese medicine (TCM) is a system of healing that is thousands of years old. It has long been utilized in the Chinese culture to treat the complex of symptoms that Western medicine terms diabetes mellitus. This article will outline the key concepts and therapies of TCM that play a role in the evaluation and treatment of diabetic patients.

Traditional Chinese Medicine in the Treatment of Diabetes

Maggie B. Covington, MD 154

Diabetes is one of the most prevalent chronic diseases in the United States. The morbidity and mortality associated with the disease is significant and derives primarily from complications of persistent hyperglycemia. Longstanding hyperglycemia has been shown to lead to vascular complications involving large and small blood vessels, such as arteriosclerosis, glomerulosclerosis, and retinopathy. Diabetic neuropathy, characterized by pain and paresthesias, is among the most frequent complications of longstanding, poorly controlled diabetes and is often associated with a reduction in physical activity and with sleep disturbances.1,2

Western or conventional therapies for diabetes have been geared toward regulating blood glucose with a combination of diet modification, insulin and/or oral pharmacological agents, weight loss when appropriate, and exercise. Although Western medicine and Traditional Chinese medicine (TCM) share the diabetes treatment goals of reducing symptoms and preventing complications, their approaches to conceptualizing, diagnosing, and treating the disease are very different. This article will outline the key concepts and therapies of TCM that play a role in the evaluation and treatment of diabetic patients.

Traditional Chinese Medicine TCM is a system of healing that originated thousands of years ago. It has evolved into a well-developed, coher-

ent system of medicine that uses several modalities to treat and prevent illness. The most commonly employed therapeutic methods in TCM include acupuncture/moxibustion, Chinese herbal medicine, diet therapy, mind/body exercises (Qigong and Tai Chi), and Tui Na (Chinese massage).3

TCM views the human body and its functioning in a holistic way. From this perspective, no single body part or symptom can be understood apart from its relation to the whole. Unlike Western medicine, which seeks to uncover a distinct entity or causative factor for a particular illness, TCM looks at patterns of disharmony, which include all presenting signs and symptoms as well as patients' emotional and psychological responses. Humans are viewed both as a reflection of and as an integral part of nature, and health results from maintaining harmony and balance within the body and between the body and nature.3

Two basic TCM theories explain and describe phenomena in nature, including human beings: Yin-Yang Theory and the Five Phases Theory or Five Element Theory.

Yin and Yang are complementary opposites used to describe how things function in relation to each other and to the universe. They are interdependent--one cannot exist without the other, and they have the ability to transform into each other.3 The traditional Yin-Yang symbol (Figure 1)

Diabetes Spectrum Volume 14, Number 3, 2001

Within the model of Five Phases, the body. There are 12 regular meridi-

From Research to Practice / Complementary & Integrative Medicine

each element is associated with an ans and 8 extra or "curious" meridi-

organ. Wood is associated with the ans. The 12 main meridians corre-

liver, fire with the heart, earth with spond to 12 major functions or

the spleen-pancreas-stomach, metal "organs" of the body (such as liver,

with the lungs, and water with the kidney, heart).

kidneys. In addition, other phenome- The Chinese concept of organs cor-

na, such as seasons, cardinal direc- responds only loosely to the Western

tions, weather, color, and emotions, concept. TCM associates specific

are associated with each element. functions, symptoms, emotions, col-

Within the TCM model, diagnostic ors, and tastes with each organ,

information is gained by finding out whereas the Western view is limited

patients' favorite season, color, and primarily to function.

predominant emotion(s).

Qi must flow in the correct quanti-

Figure 1. The Yin-Yang symbol

Key Concepts Within TCM

ty and quality through the meridians and organs for health to be main-

Qi

tained. Acupuncture, the insertion of

depicts the Yin (the dark side) flowing Qi (pronounced "chi") is translated thin, solid metal needles, is performed

into the Yang (the light side) and vice into English as vital energy. It is on 1 or more of the 361 acupuncture

versa. The dots within each side sym- defined in terms of function rather points distributed along the meridians

bolize that there is always a bit of Yin than as a discrete substance, and it is in order to regulate and promote the

within Yang and a bit of Yang within what animates us and allows us to proper flow of Qi.5 Other techniques

Yin; there are no absolutes. All physi- move and maintain the activities of may be used to stimulate acupuncture

ological functions of the body, as well life. The origins of Qi include "con- points, such as moxibustion, in which

as the signs and symptoms of disease, genital"' (prenatal) Qi--that which is the herb "moxa" (Artemesia vulgaris)

can be differentiated on the basis of inherited from our parents--and is used to warm the acupuncture point

Yin and Yang characteristics.

"acquired" Qi--that which is incor- either above or on the skin. Applied

The Chinese character for Yin orig- porated from food and air.4

pressure (acupressure), lasers, and

inally meant the shady side of a slope. Two major patterns of disharmony magnets also may be used to stimulate

Qualities characteristic of Yin include are associated with Qi. Deficient Qi acupuncture points.

cold, stillness, darkness, inwardness, occurs when there is insufficient Qi to

passivity, decrease, and downward- perform the functions of life. Deficient Jing

ness. In contrast, the Chinese charac- Qi may affect one or more organs or Jing, usually translated as "essence,"

ter for Yang originally meant the the entire body. If the latter occurs, is the substance that is the underpin-

sunny side of the slope, and qualities then the patient may experience ning of all organic life. Qi is responsi-

characteristic of Yang include heat, lethargy, fatigue, and lack of desire to ble for the ongoing day-to-day move-

movement, brightness, outwardness, move. Stagnant Qi refers to impair- ments and function of the body,

stimulation, excitement, increase, and ment of the normal movement of Qi whereas Jing can be considered an

upwardness.4 Illnesses that are charac- through the meridians (see discussion individual's constitutional makeup.

terized by coldness, weakness, slow- below) and may result in aches and According to TCM, Jing is stored in

ness, and underactivity are considered pains in the body.4

the kidneys.4

Yin (e.g., hypothyroidism: cold limbs,

fatigue, slowed metabolism). Illnesses Meridians

Shen

that manifest strength, forceful move- Meridians are the channels or path- Shen is considered to be the psyche or

ment, heat, and overactivity are Yang ways through which Qi is constantly spirit of the individual. Shen is the

(e.g., acute infections with fever and flowing and circulating throughout vitality behind Jing and Qi in the

sweating).

human body. The three elements

The theory of Five Phases, Wu

together--Qi, Jing, and Shen--are

Xing, is a means of classifying phe-

referred to collectively in TCM as the

nomena in terms of five basic process-

"Three Treasures" and are believed to

es represented by the elements wood,

be the essential components of life.5

fire, earth, metal, and water. There

exists a dynamic balance and relation-

Blood

ship among the elements such that if

According to TCM, the major activity

the balance is interrupted or

of the blood is to circulate through

destroyed, pathological changes may

the body, nourishing and moistening

occur. The clockwise movement of

the various organs and tissues.

one element into the next (wood, fire,

Disharmonies of the blood may mani-

earth, and so forth) whereby one ele-

fest as "deficient" blood or "con-

ment generates, acts on, or promotes

gealed" blood. If deficient blood exists

the following element, is referred to as

and affects the entire body, the patient

the Sheng cycle. The Ke cycle represents an element acting on or controlling another element in a different order (Figure 2).3

Figure 2. Diagram of The Five Phases, illustrated are the Sheng and Ke cycles

may present with dry skin, dizziness, and a dull complexion. Congealed blood may manifest as sharp, stabbing pains accompanied by tumors, cysts,

155

or swelling of the organs (i.e., the liver).4 The key organs associated with blood are the heart, liver, and spleen.

Fluids Fluids are bodily liquids other than blood and include saliva, sweat, urine, tears, and semen. Fluids act to moisten both the exterior (skin and hair) and the internal organs. Disharmonies of fluids may result in dryness and excess heat. The key organs involved in the formation, distribution, and excretion of fluids are the lungs, spleen, and kidneys.3

Diagnosis in TCM When evaluating patients with a chronic illness such as diabetes, TCM practitioners take a detailed, multisystem case history and supplement this information with observations that give information about the state of the patient's health. These observations include the shape, color, and coating of the tongue; the color and expression of the face; the odor of the breath and body; and the strength, rhythm, and quality of the pulse. Many practitioners will palpate along meridians to detect points of tenderness that may indicate a blockage in the flow of Qi at that point.6

One of the most common ways of differentiating symptoms and syndromes in TCM is according to the Eight Principles--four pairs of polar opposites: Yin and Yang, Interior and Exterior, Cold and Heat, and Deficiency and Excess. Characteristics of the Eight Principles are summarized in Tables 1 and 2.4

and all three are associated with Yin deficiency. At some point during the course of their illness, most people with diabetes manifest symptoms of all three types.

According to TCM, Xiao-ke is attributed to three main factors: improper diet (consuming large quantities of sweets, fatty or greasy foods, alcohol, and hot drinks such as hot coffee or tea), emotional disturbances (stress, anxiety, depression,) and a constitutional Yin deficiency (fatigue, weakness, lethargy, pale complexion).7 To the Western ear, TCM diagnoses sound esoteric, even poetic. In the case of a person with diabetes presenting with symptoms of excessive thirst, the diagnosis can be described as kidney

Yin deficiency along with lung Yin deficiency and "internal heat that consumes fluids, thus bringing on wasting and thirsting."7

TCM Therapies Unlike Western medicine, TCM is not concerned with measuring and monitoring blood glucose levels in diabetic patients. Treatment is individualized and geared toward assessing and treating the symptoms that compose patterns of deficiency and disharmony.

Acupuncture/moxibustion Acupuncture and moxibustion traditionally have been used in the treatment of diabetes to reduce blood glucose levels and normalize endocrine

Table 1. Summary of TCM Main Excess/Deficiency and Heat/Cold Signs

General Signs

Tongue

Excess pattern Ponderous, heavy movement; heavy, coarse respiration; pressure and touch increase discomfort

thick moss

Deficiency patterns Frail, weak movement; tiredness; shortness of breath; pressure relieves discomfort; inactive; passive appearance; low voice; dizziness; little appetite

pale material; thin moss

Heat patterns Red face; high fever; dislike of heat; cold reduces discomfort; rapid movement; outgoing manner; thirst or desire for cold drinks; dark urine; constipation

red material; yellow moss

Cold patterns

Pale, white face; limbs cold; fear of cold; heat reduces pale material;

discomfort; slow movement; withdrawn manner; no

white moss

thirst, or a desire for hot drinks; clear urine; watery stool

Pulse strong weak

rapid

slow

Table 2. Signs of Yin and Yang Patterns4

TCM Classification of Diabetes

Examination Yin Signs

Yang Signs

The Chinese language includes two terms for diabetes. The traditional name, Xiao-ke, correlates closely with diabetes in most instances. Xiao-ke syndrome means "wasting and thirsting." The more modern term, Tangniao-bing, means "sugar urine illness."

Looking

quiet; withdrawn; slow, frail manner; patient is tired and weak, likes to lie down curled up; no spirit; excretions and secretions are watery and thin; tongue material is pale, puffy and moist; tongue moss is thin and white

agitated, restless, active manner; rapid, forceful movement; red face; patient likes to stretch when lying down; tongue material is red or scarlet, and dry; tongue moss is yellow and thick

Reference to diabetes by the traditional Listening and voice is low and without

voice is coarse, rough, and

term appears in the earliest texts, Smelling

strength; few words; respiration

strong; patient is talkative;

including the first medical text in

is shallow and weak; shortness of respiration is full and deep;

Chinese history, Huang Di Nei Jing, or

breath; acrid odor

putrid odor

The Yellow Emperor's Inner Classic. Diabetes is classically divided into

three types: upper, middle, and lower Xiao-ke. Each has characteristic symptoms. The upper type is characterized by excessive thirst, the middle

Asking

feels cold; reduced appetite; no taste in mouth; desires warmth and touch; copious and clear urine; pressure relieves discomfort; scanty pale menses

patient feels hot; dislikes heat or touch; constipation; scanty, dark urine; dry mouth; thirst

by excessive hunger, and the lower by Touching

frail, minute, thin, empty, or

full, rapid, slippery, wiry,

excessive urination. These types are

otherwise weak pulse

floating, or otherwise strong

closely associated with the lungs,

pulse

stomach, and kidneys, respectively,

156

Diabetes Spectrum Volume 14, Number 3, 2001

function. Clinical and experimental pain, are mediated in part by the Herbal medicine

From Research to Practice / Complementary & Integrative Medicine

studies have demonstrated that release of endogenous opioids from Herbal medicine has been an integral

acupuncture has a beneficial effect on the spinal cord, brainstem, and hypo- part of TCM for more than 2,000

lowering serum glucose levels.8,9

thalamus. In addition, it has been years. Many herbal formulations have

A typical acupuncture treatment demonstrated that neurotransmitters, been developed and are used in the

involves needling 4?12 points and such as serotonin and substance P, treatment of diabetes. The Huang Di

allowing the needles to remain in are released during acupuncture treat- Nei Jing (Yellow Emperor's Inner

place for ~10?30 min. Needles may be ments. Increases in local blood flow Classic), which dates from the Han

stimulated manually or by using a and vasodilation and increased levels Dynasty 206 B.C.?220 A.D., listed 13

small electrical current. In addition, of cortisol have also been demonstrat- herbal formulations, 9 of which were

the practitioner may warm the points ed.10 A 300% increase in plethysmo- patent medicines including pills, pow-

with moxibustion.

graphic recordings of blood flow has ders, plasters, and tinctures.12 The

The number of treatments for been demonstrated in the digits of sources of Chinese remedies are varied

chronic conditions such as diabetes limbs stimulated with electroacupunc- and include plants, minerals, and ani-

ranges from 6 to 14 sessions. This ture.10

mal parts.3

may be followed by "tune up" ses- A recent study of 46 patients with Chinese herbs have specific func-

sions every 2?6 months.6 The cost for painful peripheral neuropathy evalu- tions (i.e., warming, heat-clearing,

the initial session is about $75 ?$150, ated acupuncture analgesia to deter- eliminating dampness, and cooling)

with the follow-up visits costing mine its short- and long-term efficacy. and can be classified according to

$65?100 each. Third-party payment Using TCM acupuncture points, 34 those functions. They are also classi-

for complementary and alternative patients (77%) experienced signifi- fied according to four natures (cool,

therapies varies from state to state. cant improvement in their symptoms. cold, warm, and hot) and five tastes

Some insurers, such as Blue Cross After a follow-up period of 18?52 (sweet, pungent, bitter, sour, and

Blue Shield, cover certain therapies weeks, 67% were able to stop or sig- salty).4 Herbs may be prescribed indi-

for specific diagnoses only, i.e., nificantly reduce their pain medica- vidually or as part of a formula.

acupuncture for pain-related diag- tions. Only 8 (24%) required addi- Formulas promote the effective use

noses. For an additional cost, a few tional acupuncture treatment; 7 of herbs.3 A typical formula has four

insurance companies offer a separate (21%) stated that their symptoms had components, including:

complementary medicine package cleared completely.11

1. The Chief (principal) ingredient,

that allows the insured to see comple- A randomized, sham-controlled,

which treats the principal pattern

mentary medicine practitioners at a crossover study of 50 adults with type

of disease,

discounted rate.

2 diabetes evaluated the effectiveness 2. The Deputy (associate) ingredient,

Auricular acupuncture (inserting of Percutaneous Nerve Stimulation

which assists the Chief ingredient

needles into specific points on the ear) (PENS) therapy in the treatment of

in treating the major syndrome or

may be used alone or in conjunction neuropathic pain. PENS is a modern

serves as the main ingredient

with body acupuncture. According to adaptation of acupuncture that uses

against a coexisting syndrome,

TCM, the entire body is represented percutaneously placed acupuncture 3. The Assistant (adjutant) ingredient,

on the ear. Examination of the ears needles to stimulate peripheral senso-

which enhances the effect of the

often reveals surface irregularities, ry and motor nerves innervating the

Chief ingredient, moderates or

such as superficial capillaries, scars, region of neuropathic pain. The

eliminates the toxicity of the Chief

pitting, pimples, flaking, discol- results showed that active PENS treat-

or Deputy ingredients, or can have

oration, or swelling. Upon probing ment improved neuropathic pain

the opposite function of the Chief

the auricle of the ear with a rounded, symptoms in all patients. In addition

ingredient to produce supplement-

blunt instrument the practitioner may to reducing pain, the treatment

ing effects, and

discover tender areas that may corre- improved physical activity levels, 4. The Envoy (guide) ingredient,

spond to the area of the patient's pain sense of well-being, and quality of

which focuses the actions of the

or disturbance.10 A sample auricular sleep and reduced oral non-opioid

formula on a certain meridian or

treatment for diabetes might include analgesic medication requirements.2

area of the body or harmonizes

needling a master point, for example, Because of poor peripheral circula-

and integrates the actions of the

Shen Men (a good point for almost all tion and slowed healing of skin infec-

other ingredients.3

disorders), along with the endocrine tions and ulcerations, needling of the

point, lung point (for thirst), stomach lower extremities in diabetic patients Herbal prescriptions for diabetes

point (for hunger), kidney and blad- should be performed with extreme are formulated or prescribed based on

der points (for frequent urination), caution and sterile technique. In gen- the patient's predominant symptoms.

and pancreas point (for increasing eral, however, acupuncture appears to For instance, a patient presenting pri-

insulin secretion).7

be a relatively safe form of treatment. marily with excessive thirst (lung Yin

Peripheral neuropathy, one of the An extensive worldwide literature deficiency) might be given a single

most common complications of type search identified only 193 adverse herb, such as radix panacis quinque-

2 diabetes, occurs most often in the events (including relatively minor folii; or a combination of herbs in a

distal extremities and typically affects events, such as bruising and dizziness) patent formulation such as yu chuan

the sensory, motor, and autonomic over a 15-year period. There have wan, which is used in general to treat

systems. Acupuncture has been been approximately 86 reported cases diabetes of mild to moderate severity

demonstrated to exert a beneficial of hepatitis B and 1 case of HIV trans- and specifically to treat excessive

effect on neuropathic pain.2 The mission. In all of these cases, nondis- thirst due to Yin deficiency,12 and ba

effects of acupuncture, particularly on posable needles were used.6

wei di huang tang ("eight-ingredient

157

pill with rehmannia"), which was Discontinuing conventional med- should be smaller, eaten more fre-

originally used to treat people exhibit- ications in favor of herbal formula- quently, and eaten at regular times

ing weakness, fatigue, and copious tions may lead to serious complica- each day.

urine soon after drinking water.13

tions such as significant hyper-

Some of the most commonly used glycemia, and combining conventional Qigong

herbal substances for diabetes in hypoglycemic agents with herbal Qigong (pronounced "chi gong") is lit-

TCM include:

preparations without proper monitor- erally translated as "function of Qi." It

1. Panax ginseng (Korean ginseng), ing could lead to hypoglycemia.

emphasizes the connection between

which has a long history of use as a The Food and Drug Administration the mind and body. It is a meditative

hypoglycemic agent. At least five (FDA) does not regulate herbs, miner- method that consists of breathing tech-

constituents of this herb have been als, animal products, and patent for- niques that can be combined with

shown to exert hypoglycemic mulas that come into the United States body movements in order to regulate,

effects. In one study, treatment from China. Herbal products are con- harness, and enhance Qi. Qigong is

with ginseng lowered blood glucose sidered dietary supplements according used as a means of promoting health,

levels and improved mood and psy- to the Dietary Supplement and Health healing, spiritual growth, and overall

chological performance as com- Education Act (DSHEA) of 1994; well-being. While Qigong is not typi-

pared with placebo. Recommended therefore, the manufacturers do not cally used as a major treatment modal-

dosage is 100?200 mg/day.14

need FDA approval or evaluation for ity for diabetes, it has been found to be

2. Momodica charantia (balsam safety, purity, and efficacy before a valuable adjunctive therapy for this

pear), which is dried, powdered, bringing their products to market. condition. There are specific Qigong

and made into pills. A dosage of There have been reports of some for- exercises for diabetes.15

18 g/day has been shown to reduce mulas imported from China contain-

blood glucose.15

ing heavy metals such as lead and mer- Tui Na

3. Lagenaria siceraria (bottle gourd), cury and of others being deliberately Tui Na is a traditional form of

given as a decoction or pills. The adulterated with conventional Western Chinese massage that uses hand

recommended dose is 3 g/day. pharmaceuticals, such as corticos- manipulations, such as pulling, knead-

This, too, has been shown to teroids, anti-inflammatory agents, and ing, pushing, and grasping to stimulate

reduce blood glucose levels.15

benzodiazepines.16

acupuncture points and other parts of

4. Psidium gnajava, taken in the form

the body to create balance and harmo-

of fresh leaves or as an infusion Diet therapy

ny in the system. It can be used effec-

and drunk as a tea. The dosage is 9 According to TCM, diet plays an tively in lieu of acupuncture in patients

g/day. It acts to reduce blood glu- important role in maintaining health who have an aversion to needles, par-

cose levels.15

and treating disease. In the TCM par- ticularly pediatric patients.13

adigm, foods are valued and pre-

The above herbs do not appear to scribed for their energetic and thera- Conclusion

increase insulin levels, but rather peutic properties rather than solely for TCM does not offer a cure for dia-

enhance carbohydrate utilization.15 their chemical makeup. Attention is betes, but instead aims to optimize the

Patients should have their type of dia- paid to the quantity, quality, method body's ability to function normally.

betes and any other diagnoses con- of preparation, and time of food There is still a great need for more

firmed before initiating any herbal intake, as well as to the patient's body and better research on the efficacy

treatment. In addition, one should type, age, vitality; geographic loca- and safety of both Chinese herbals,

first ascertain the credibility of the tion; and seasonal influences.

which are being used along with or in

herbal therapist by inquiring about Because TCM defines diabetes as a lieu of Western pharmaceuticals, and

where and for how long the person disease characterized by Yin deficien- acupuncture in the care of diabetic

received training and about member- cy and excess internal heat, an exam- patients. Patients, TCM practitioners,

ship in herbal associations such as the ple of a dietary prescription would be and physicians who choose to inte-

American Herbalists Guild. To to consume spinach, which is cooling, grate the two forms of care must all

become members, herbalists must sub- "strengthens all the organs, lubricates recognize the importance of careful

mit three letters of reference from the intestines, and promotes urina- monitoring of blood glucose levels, as

other professional herbalists, a tion."7 A recommendation might be well as monitoring for potential side

description of their training, and an to boil tea from spinach and drink 1 effects such as drug-herb interactions.

account of at least 4 years of experi- cup three times/day. Other foods con- As always, in seeking to integrate

ence working with medicinal herbs. sidered to be cooling and beneficial different traditions and forms of heal-

As part of their training, TCM practi- for diabetes include vegetables and ing, we are seeking to offer patients

tioners learn about the proper use of grains, such as celery, pumpkin, soy- the safest, most effective care possible.

herbals.

beans (i.e., tofu, soymilk), string Remaining open to alternative forms

Many Chinese herbs and formula- beans, sweet potato/yam, turnips, of care and educating ourselves about

tions have been used safely for cen- tomato, wheat bran, and millet. Fruit the safety and efficacy of these modal-

turies in the hands of trained TCM remedies, which act in specific thera- ities can benefit us all.

practitioners. It is important to recog- peutic ways, include crab apple,

nize, however, that data on drug-herb guava, plum, strawberry, and mulber- References

interactions are scarce, and there are clear contraindications to the use of specific herbs in certain populations, such as pregnant women.13

ry.7 It is generally recommended that patients eat a wide variety of seasonal foods and avoid or minimize consumption of sweets and fruits. Meals

1Berman BM, Kaczmarczyk J, Swyers JP: Complementary and alternative medicine herbal therapies for diabetes. J Assoc Acad Minor Phys 10:10?14, 1999

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