Diabetes Mellitus

Diabetes mellitus is a group of disorders that all lead to an elevation of glucose in the blood (hyperglycemia). Hypertension is due to a hormonal disorder whereby the pancreas is not able to produce enough insulin to regulate the blood sugar levels. Diabetes mellitus can be accompanied by an array of secondary complications, such as blindness, renal failure, lower lib amputations, cardiovascular disease, dementia, stroke, and coma¹.

There are three main types of Diabetes.

1. Insulin-dependent Diabetes is considered an autoimmune disease as the immune system attacks the insulin-producing beta cells in the Pancreas and destroys them. 2. Non-insulin-Dependent diabetes, is the most common form of diabetes and makes up 90-95% of the people with diabetes (USA). This type usually develops in adults over the age of 40 and is characterized by elevated levels of insulin in the vicinity of about 2-3 times the normal amount. Non-insulin dependent diabetes can be controlled with patient management focusing on the diet, exercise programs, stress management etc. and does not always require drug intervention where as Insulin dependent requires regular injections of insulin to prevent death. The third type of diabetes develops or is discovered only during pregnancy and is called Gestational Diabetes. This type usually disappears after the pregnancy².

From a contemporary Western Medical perspective, there are three main indicators for diabetes mellitus known as the three “polys”:

Polyuria= an inability to reabsorb water, resulting in excessive urine production.
Polydispia= excessive thirst.
Polyphagia= excessive eating.

Xiao Ke is the Chinese name for diabetes and it translates into, Xiao “wasting” and Ke “thirst”. The history of treating Xiao Ke with acupuncture stems back about 2000 years and one of the earliest discussions on the topic is found in the Yellow Emperor’s Inner Classic. The contemporary Chinese term for Diabetes is tang-niao-bing and its translation “sugar urine illness” reflects the Western medical model for this disease.

From a TCM perspective the three “polys” outlined above are understood in the following way:
Upper wasting: excessive drinking involving the Lungs
Middle wasting: excessive appetite involving the Stomach and Spleen
Lower wasting: excessive drinking with copious urination involving the Kidneys³

A fuller description of the mechanisms involved and current treatment protocols from a TCM viewpoint shall be the focus of discussion in the following sections.

¹ Principles of anatomy and physiology, Tora and Grabowski, eighth ed, 1996, Harper Collins, USA
² Journal of Chinese Medicine, number 58, September 1998, article by Clinton J. Choate
³ Journal of Chinese Medicine, number 15, May 1984, article by Professor Qin Mao-Liang

Aetiology

According to the principles of TCM one of the main causes of Diabetes is an inappropriate diet, in the form of over consumption of fatty, greasy, pungent and sweet food. Other main causes include emotional disturbance and the presence of a Yin Xu constitution⁴.

Over consumption of fatty, greasy, pungent and sweet food, hot drinks and alcohol impairs the transformation and transportation functions of the Spleen and Stomach, which in turn leads to the generation of internal heat. Internal heat leads to the consumption of body fluids and results in increased thirst and hunger⁵. In the Su Wen it explains this mechanism in the following way:

Fat causes interior heat while sweetness causes fullness in the middle burner. The Qi therefore rises and overflows and the condition changes into that of wasting and thirsting⁶.

Long-term duration of internal heat leads to injury of Yin and when the body fluids are consumed they fail to nourish the Lung and Kidneys. In diabetes the related pathological mechanisms always involve Yin deficiency and dry heat, each having the ability to influence the other.

Long-term emotional disturbance is a contributive factor to diabetes as excessive emotions leads to Qi stagnation, which in turn will generate into heat and consume Yin as in situation of Liver Qi stasis. Liver Qi becomes constrained from/or due to anger, resentment and frustration. As a result the Qi stasis becomes Liver-fire, which then consumes Yin and creates Lung and Stomach Yin Xu. Over-thinking injures the spleen, the spleen is where food and fluid is absorbed into the body and disharmony of this function can be related to the absorption and processing of thoughts and emotions. The mechanisms involved with the Spleen are as discussed prior.

When a person is constitutionally Yin Xu, excessive sexual activity prolonged stress or illness and overwork can consume the essence. This type of pattern begins as Kidney Yin deficiency that can then become Kidney-fire blazing and in the long term can develop to Kidney-Qi or Kidney-Yang deficiencies⁷.

Summary of the main patterns involved:

1. Thirst – Lung dryness from dry heat consuming Lung fluids
2. Excessive appetite – Stomach heat from heat retained in the Stomach & Spleen
3. Frequent urination – Kidney deficiency

⁴ Journal of Chinese Medicine, number 59, January 1999, article by Clinton J. Choate
⁵ ibid.
⁶ Su Wen, Simple Questions, chapter 47
⁷ Journal of Chinese Medicine, number 59, January 1999, article by Clinton J. Choate

Differentiation and treatment according to the Three Jaio’s

The upper Jiao

Pattern: Injury of body fluids by Lung-heat
Differentiation: S/S excessive thirst, dry mouth and throat, frequent urination, night sweats
Tongue: Red body with dry yellow coat
Pulse: Rapid and thready or wiry

Treatment principle: Tonify the Lungs, tonify Yin and clear heat.

Points used

St-36: Used in accordance with 5-phase theory of treatment, tonifying the mother to treat the child. The Stomach channel being earth, and the Lung channel metal. This point also has the function to tonify the Spleen & Stomach and will strengthen the digestion and increase the transformation and transportation functions. This in turn will aid in the movement of Qi in the middle Jiao and assist in the production of body fluids.

Ki-3: Used to tonify Kidney-Yin. As Ki- 3 tonifies the kidneys, this will also support the Lungs.

Ren-23: This point promotes the production of body fluids. According to Professor Qu Maolian, the point is to be needled to gain de-qi and then partially withdrawn and then redirected to either side to stimulate Jinjin and Yuye (two extra points). These points are near the base of the tongue and help to stimulate secretion of body fluids⁸.

Lu-5: This point is able to clear heat from the lung and regulate the water passages.

Bl-13: This point clears both Xs/Xu heat from the Lung and tonifies Lung-Yin.

According to clinical experience, treatments should be given daily or every other day. Apply reinforcing method and in cases of severe thirst with a very red tongue, apply reducing method. Needles should be retained for 30 minutes⁹.

The Middle Jiao

Pattern: Injury of Yin by stomach dryness
Differentiation: S/S excessive appetite, constipation, halitosis, dry lips, burning sensation in the epigastrium, preference for cool drinks.
Tongue: Red body with thick yellow coat
Pulse: Rapid and full
Treatment principle: clear Stomach dryness, clear heat and tonify Yin.

Points used

Sp-6: This is the main point to tonify Yin, as it is the meeting point of the three leg yin channels.

Ren-12: This point is used to harmonize the Middle Jiao and also to tonify the Stomach.

St-44: This point is used to clear stomach-heat and remove dryness.

St-36: This point is used for clearing stomach dryness by nourishing stomach yin and regulating the appetite.

Ki-3: Kidney 3 is used to tonify yin and is able to support the yin of the whole body.

WEIGUANXIASHU (Stomach Controller Lower Shu): An extra point located 1.5 cun lateral to the lower border of T8. This point was first mentioned in the Thousand Ducat Formulas and is indicated for wasting and thirsting.

If heat is severe then use the reducing method, otherwise reinforcing method is recommended. The needles should be retained for 30 minutes and the treatment is recommended every day of every second day.

⁸ Nanjing Seminars Trancript, Qiu Mao-lian and Su Xin-Ming, Journal of Chinese Medicine, 1984
⁹ Journal of Chinese Medicine, number 15, May 1984, article by Professor Qin Mao-Liang

The Lower Jiao

Pattern: Exhaustion of Kidney essence and Kidney-Yin
Differentiation: S/S excessive urination, lower lumber pain, constipation, blurred vision, dizziness, poor memory, nocturnal emission, weak knees
Tongue: Red body with scanty coating
Pulse: Rapid and thin

The excessive urination is a manifestation of Kidney Qi not firm. If Kidney-Yang is also deficient there may be cold limbs.

Treatment principle: Strengthen the function of the Kidneys and nourish the essence

Points used

Ren-4: This point is a local point for the Bladder. Ren 4 also tonifies the Kidneys, and fortifies the original Qi and essence.

Bl-23: Regulates urination and the water passages, and tonifies and the Kidneys and benefits the essence.

Ki-3: Tonifies the Kidneys and nourishes Kidney Yin.

Sp-6: Tonifies the Kidneys and nourishes Yin.

All these points are needled with a reinforcing method and it’s recommended to be done ever second day. The needles are retained for 30 minutes.

Ear Acupuncture

The following ear acupuncture points can be used in conjunction with the above listings and differentiations according to the following signs and symptoms:

Thirst: use the Endocrine, Lung, and thirst points
Hunger: use the Endocrine and Stomach point
Frequent urination: use the Endocrine, Kidney and Bladder points
Increasing insulin: use the Pancreas point

If ear acupuncture points are to be used primarily then the points are to be needled 2-3 times a week and retained for 20-30 minutes each time.

Discussion

In clinical practice, patients commonly present with mixed patterns. The treatment should be given according to the most predominant differentiating signs and symptoms. Where there are clear signs of two of the excesses, e.g. thirst and excessive appetite, treat both. Additional points may be added to treat other inter-related signs and symptoms that may arise as a result of the patterns discussed prior. As with all disharmonies treated by TCM, the practitioner must be flexible in approach in order to build an accurate picture of the patterns involved for each individual case and points must be added that most accurately address any additional branching signs and symptoms.

The following is a direct transposition of an article in the Journal of Chinese Medicine number 59 January 1999 article by Clinton J. Choate. It outlines all the possible branching manifestations including the points required to treat them. I have chosen to present this section in this way in-order to give the most accurate presentation of his valuable experience and research:

If there is thirst, a yellow dry tongue coating and an overflowing pulse, select points from yangming channel such as Quchi L.I.-11, Jiexi ST-41, Hegu L.I.-4 etc.

If there is Yin deficiency and uprising of Yang, with symptoms such as low-grade fever, night sweats, malar flush, deep-red tongue body and a fine and rapid pulse, select Dazhui DU-14 and Yinxi HE-6 to clear deficiency heat.

If night sweating is severe, add Houxi SI-3.

Kidney deficiency can lead to qi deficiency. Alternatively heat can consume Stomach Yin leading to Qi deficiency. In the case of qi deficiency symptoms such as shortness of breath after exertion, spontaneous sweating, and a deep, thready pulse, apply moxibustion to Qihai REN-6 and Guanyuan REN-4.

In the case of Kidney yang deficiency with cold limbs, lower limb oedema, copious urination, a pale tongue with white coating, and a thready, deep, and weak pulse, apply moxibustion to Mingmen DU-4 and Guanyuan REN-4.

For increased appetite accompanied by muscle atrophy, add Pirexue (N-BW-10) [0.5 cun lateral to the lower border of the spinous process of the sixth thoracic vertebra, corresponding to one of the Huatuojiaji (M-BW-35) points], Weishu BL-21 and Zhongwan REN-12.

Severe thirst of wasting and thirsting disorder: Yongquan KID-1 and Xingjian LIV-2 (Ode of One Hundred Symptoms).

Wasting and thirsting disorder with great desire to drink: Rangu KID-2, Yishe BL-49 and Guanchong SJ-1 (Classic of Supplementing Life with Acupuncture and Moxibustion).

Wasting and thirsting disorder with great desire to drink: Rangu KID-2, Yishe BL-49, Chengjiang REN-24 and Guanchong SJ-1 (Thousand Ducat Formulas).

Wasting and thirsting disorder: Ranggu KID-2, Chengjiang REN-24, Jinjin (M-HN-20), Yuye (M-HN-20), Renzhong DU-26, Lianquan REN-23, Quchi L.I-11, Laogong P-8, Taichong LIV-3, Xingjian LIV-2, Shangqiu SP-5 and Yinbai SP-1 (Great Compendium of Acupuncture and Moxibustion).

Kidney deficiency wasting and thirsting disorder, absence of sweating, difficulty in moving the lumbar spine, distension of the abdomen and pain of the lateral costal region: Yishe BL-49 and Zhonglushu BL-29 (Classic of Sup-plementing Life with Acupuncture and Moxibustion).

Thirst and emaciation: Chengqiang REN-24, Shentang BL-44, Guanchong SJ-1 and Rangu KID-2 (Prescriptions for Universal Benefit).

Thirst and emaciation: use up to 100 cones of moxa at Guanyuan REN-4 (Book of Bian Que’s Secrets).

Weiguanxiashu (M-BW-12), Feishu BL-13, Pishu BL-20, Shenshu BL-23, Zusanli ST-36 and Taixi KID-3. For exces-sive thirst add Shaoshang LU-11, Yuji LU-10 and Geshu BL-17. For increased appetite accompanied by emaciation of the muscles add Pirexue (N-BW-10), Weishu BL-21 and Zhongwan REN-12. For frequent urination add Guanyuan REN-4, Fuliu KID-7 and Shuiquan KID-5.

Clinical experience

Research done in the United States by the Institute of Traditional Chinese Medicine on diabetes says ‘In general, better results are obtained with acupuncture and with Chinese herbs when it is started earlier in the chronic process rather than later, when many complications may have developed’. Results would also be much more impressive if there was more intensity of treatment such as daily acupuncture instead of prescribing one pill across the board. The fact that one in four individuals experience a drop in their sugar levels leaves quite an optimistic outlook for someone with diabetes¹⁰.

The Institute of Traditional Chinese Medicine treated thirteen cases of diabetes in 1982 with moxibustion and dietary therapy. The treatment procedure for the administering of the moxibustion was as follows: moxibustion was used with a slice of ginger underneath and approximately 30 cones were used on each point. Treatment was carried out every second day for a duration of 25 days. The clients signs & symptoms were differentiated according to the three levels, upper, middle and lower and the points were chosen accordingly. Nine patients showed good results (drop of 15% or higher in blood sugar levels) after just two treatments. Ten of the patients’ symptoms of excessive appetite vanished completely and seven of the patients who had the symptom of excessive thirst reported no longer having this complaint after this period¹¹.

¹⁰ Treatment of Diabetes with Acupuncture and herbs, Institute for Traditional Medicine, Portland, Oregon

¹¹ Treatment of Diabetes with Moxibustion, Lin Yungui, Xu Lanying, Lu Xiling and Wu Ruirong, Journal of Traditional
Chinese Medicine, 1994

Patient Management

Approximately 50% of new cases of diabetes can be controlled adequately by diet alone, 20-30% will need an oral hypoglycaemic drug and 20of 305 will require insulin.

The importance of lifestyle changes such as taking regular exercise, observing a healthy diet, reducing alcohol consumption and stopping smoking should not be under estimated in improving blood sugar levels but many people particularly the middle aged and elderly find them difficult to sustain.

A suitable diet for diabetic persons should have 50% of the daily caloric intake derived from carbohydrates, of which significant amounts should be in the form of non-starch polysaccharide, as dietary fiber. Refined carbohydrates, sugars and fatty foods are main contributing factors for diabetes but unfortunately these are the major constituents of a contemporary western diet. Diabetes can be managed by a predominantly complex-carbohydrate diet, rich in fresh produce, eliminating fried/ greasy foods and the introduction of cooking procedures such as steaming and boiling¹².

Guidelines for healthy eating and good digestion for diabetics are as follows:

• The consumption of meals should be done in a clean and pleasant surrounding, free from foul odors and with plentiful fresh air
• Liquids should be consumed sparingly at meals as to increase of digestive enzymes
• A wide variety of seasonal foods should be included in the diet, as they help promote digestion and tonify and regulate the stomach and spleen
• Fruit and sweet foods should be minimized as they damage the stomach and spleen
• 3-4 light meals should be eaten at regular intervals with the largest meal being around late morning as this is the time when the stomach and spleen are strongest according to the Chinese clock
• After meals, some light exercise or perhaps a walk in the park (enjoying the fresh air) is highly advisable. There is a Chinese proverb that says “a hundred paces after each meal will allow one to live a healthy 100 years”.

The advantage of Chinese nutrition lies in its ability to adapt to the changing needs of an individual. In case of illness, rather than solely focusing on treat the particular disease, the whole person and their inter-related bio-chemical and bio-energetic systems can be addressed. The Chinese system, using food as a form of medicine is very effective in its ability to cater for the individual and often changing needs of the patient. Foods are perceived to have particular functions and properties as of the acu points and herbs.

The following examples are food groups effective in treating diabetes:

Celery: Cooling. Tonifies the Kidneys, strengthens the Spleen and Stomach, clears heat, promotes diuresis, lowers blood pressure.
Millet: Cooling. Benefits the Stomach and intestines.
Mung Bean: Cold, sweet. Clears heat, quenches thirst, resolves oedema in the lower limbs.
Mushroom (Chinese Black or Shitake): Neutral, sweet. Strength-ens the Stomach, promotes healing, lowers blood pressure, counteracts cholesterol, lowers blood fat levels.
Pearl Barley: Cooling. Promotes diuresis, strengthens the Spleen, clears heat.
Bok Choy: Cooling. Clears heat, lubricates the intestines, quenches thirst.

Taiji, Qi gong and meditation would also be a very effective in the treatment of Diabetes. These practices are extremely powerful at promoting the free flow of qi through the body, strengthening the Zang-fu and nourishing the Spirit. When done correctly, all types of stagnation and internal heat can be eliminated. Most of the exercises involve the usage of the Earth energy and can be very powerful at tonifying the Yin of the body. These practices are also extremely beneficial at treating the Shen as they can dramatic calming effects and eliminate all types of Shen disturbance. Meditation can be used to put a person into a calm state prior to meals in order to maximize the digestive function.

¹²  Davidsons Principles and Practice of Medicine, eighteenth edition, Christopher Haslet, Churchill Livingstone, 1999, USA

REFERENCES

Principles of anatomy and physiology, Tora and Grabowski, eighth ed, 1996, Harper Collins, USA
Journal of Chinese Medicine, number 58, September 1998, article by Clinton J. Choate
Journal of Chinese Medicine, number 59, January 1999, article by Clinton J. Choate
Journal of Chinese Medicine, number 15, May 1984, article by Professor Qin Mao-Liang
A Manual of Acupuncture, Peter Deadman and Mazin Al-Khafaji
Chinese Acupuncture and Moxibustion C. Zinnong (Chief Editor) Foreign Language Press, Beijing
Treatment of Diabetes with Acupuncture and herbs, Institute for Traditional Medicine, Portland, Oregon
Davidsons Principles and Practice of Medicine, eighteenth edition, Christopher Haslet, Churchill Livingstone, 1999, USA
Treatment of Diabetes with Moxibustion, Lin Yungui, Xu Lanying, Lu Xiling and Wu Ruirong, Journal of Traditional Chinese Medicine, 1994
Nanjing Seminars Trancript, Qiu Mao-lian and Su Xin-Ming, Journal of Chinese Medicine, 1984
Su Wen, Simple Questions, chapter 47
The Practice of Chinese Medicine, Giovanni Maciocia, 1994, Churchill Livingstone, UK.