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Home , Eight principles, Heart (Chinese medicine), Herbal medicine, Jing (Chinese medicine), Lung (Chinese medicine), Moxibustion

In Brief

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

Traditional Chinese Medicine in the Treatment of Diabetes

Diabetes is one of the most prevalent ent system of medicine that uses sever- chronic diseases in the . al modalities to treat and prevent ill- The morbidity and mortality associated ness. The most commonly employed Maggie B. Covington, MD with the disease is significant and therapeutic methods in TCM include derives primarily from complications of /, Chinese persistent hyperglycemia. Longstanding medicine, diet , hyperglycemia has been shown to lead mind/body exercises ( and Tai to vascular complications involving Chi), and (Chinese ).3 large and small vessels, such as TCM views the human body and arteriosclerosis, glomerulosclerosis, and its functioning in a holistic way. From retinopathy. Diabetic neuropathy, char- this perspective, no single body part acterized by pain and paresthesias, is or symptom can be understood apart among the most frequent complications from its relation to the whole. Unlike of longstanding, poorly controlled dia- Western medicine, which seeks to betes and is often associated with a uncover a distinct entity or causative reduction in physical activity and with factor for a particular illness, TCM sleep disturbances.1,2 looks at patterns of disharmony, Western or conventional therapies which include all presenting signs and for diabetes have been geared toward symptoms as well as patients’ emo- regulating blood glucose with a combi- tional and psychological responses. nation of diet modification, insulin Humans are viewed both as a reflec- and/or oral pharmacological agents, tion of and as an integral part of weight loss when appropriate, and , and health results from main- exercise. Although Western medicine taining harmony and balance within and Traditional Chinese medicine the body and between the body and (TCM) share the diabetes treatment nature.3 goals of reducing symptoms and pre- Two basic TCM theories explain venting complications, their approach- and describe phenomena in nature, es to conceptualizing, diagnosing, and including human beings: Yin-Yang treating the disease are very different. Theory and the Five Phases Theory or This article will outline the key con- Five Element Theory. cepts and therapies of TCM that play are complementary a role in the evaluation and treatment opposites used to describe how things of diabetic patients. function in relation to each other and to the universe. They are interdepen- Traditional Chinese Medicine dent—one cannot exist without the TCM is a system of healing that origi- other, and they have the ability to nated thousands of years ago. It has transform into each other.3 The tradi- evolved into a well-developed, coher- tional Yin-Yang symbol (Figure 1) 154 Diabetes Spectrum Volume 14, Number 3, 2001 Within the model of Five Phases, the body. There are 12 regular meridi- Integrative Medicine & Complementary / From Research to Practice each element is associated with an ans and 8 extra or “curious” meridi- organ. is associated with the ans. The 12 main meridians corre- , with the , with spond to 12 major functions or the spleen-pancreas-stomach, “organs” of the body (such as liver, with the lungs, and 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). must flow in the correct quanti- ty and quality through the meridians Figure 1. The Yin-Yang symbol Key Concepts Within TCM 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 . 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 “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 (), 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 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 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, 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- “” 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 repre- Figure 2. Diagram of The Five may present with dry skin, dizziness, sents an element acting on or control- and a dull complexion. Congealed Phases, illustrated are the Sheng and ling another element in a different blood may manifest as sharp, stabbing order (Figure 2).3 Ke cycles pains accompanied by tumors, cysts, 155 or swelling of the organs (i.e., the and all three are associated with Yin Yin deficiency along with Yin liver).4 The key organs associated with deficiency. At some point during the deficiency and “internal heat that con- blood are the heart, liver, and spleen. course of their illness, most people sumes fluids, thus bringing on wasting with diabetes manifest symptoms of and thirsting.”7 Fluids all three types. Fluids are bodily liquids other than According to TCM, -ke is TCM Therapies blood and include saliva, sweat, urine, attributed to three main factors: Unlike Western medicine, TCM is not tears, and semen. Fluids act to moist- improper diet (consuming large quan- concerned with measuring and moni- en both the exterior (skin and hair) tities of sweets, fatty or greasy foods, toring blood glucose levels in diabetic and the internal organs. Disharmonies alcohol, and hot drinks such as hot patients. Treatment is individualized of fluids may result in dryness and coffee or tea), emotional disturbances and geared toward assessing and treat- excess heat. The key organs involved (stress, anxiety, depression,) and a ing the symptoms that compose pat- in the formation, distribution, and constitutional Yin deficiency (fatigue, terns of deficiency and disharmony. excretion of fluids are the lungs, weakness, lethargy, pale complexion).7 spleen, and kidneys.3 To the Western ear, TCM diagnoses Acupuncture/moxibustion sound esoteric, even poetic. In the case Acupuncture and moxibustion tradi- Diagnosis in TCM of a person with diabetes presenting tionally have been used in the treat- When evaluating patients with a with symptoms of excessive thirst, the ment of diabetes to reduce blood glu- chronic illness such as diabetes, TCM diagnosis can be described as kidney cose levels and normalize endocrine practitioners take a detailed, multi- system case history and supplement Table 1. Summary of TCM Main Excess/Deficiency and this information with observations Heat/Cold Signs that give information about the state of the patient’s health. These observa- General Signs Tongue Pulse tions include the shape, color, and Excess pattern coating of the tongue; the color and Ponderous, heavy movement; heavy, coarse thick moss strong expression of the face; the odor of the respiration; pressure and touch increase discomfort breath and body; and the strength, Deficiency patterns rhythm, and quality of the pulse. Frail, weak movement; tiredness; shortness of breath; pale material; weak Many practitioners will palpate along pressure relieves discomfort; inactive; passive thin moss meridians to detect points of tender- appearance; low voice; dizziness; little appetite ness that may indicate a blockage in Heat patterns the flow of Qi at that point.6 Red face; high fever; dislike of heat; cold reduces red material; rapid One of the most common ways of discomfort; rapid movement; outgoing manner; yellow moss differentiating symptoms and syn- thirst or desire for cold drinks; dark urine; dromes in TCM is according to the Cold patterns Eight Principles—four pairs of polar Pale, white face; limbs cold; fear of cold; heat reduces pale material; slow opposites: Yin and Yang, Interior and discomfort; slow movement; withdrawn manner; no white moss Exterior, Cold and Heat, and thirst, or a desire for hot drinks; clear urine; watery stool Deficiency and Excess. Characteristics of the Eight Principles are summarized 4 in Tables 1 and 2.4 Table 2. Signs of Yin and Yang Patterns

TCM Classification of Diabetes Examination Yin Signs Yang Signs The Chinese language includes two Looking quiet; withdrawn; slow, frail agitated, restless, active terms for diabetes. The traditional manner; patient is tired and weak, manner; rapid, forceful name, Xiao-ke, correlates closely with likes to lie down curled up; no movement; red face; patient diabetes in most instances. Xiao-ke spirit; excretions and secretions likes to stretch when lying are watery and thin; tongue material down; tongue material is red syndrome means “wasting and thirst- is pale, puffy and moist; tongue or scarlet, and dry; tongue ing.” The more modern term, Tang- moss is thin and white moss is yellow and thick niao-bing, means “sugar urine illness.” 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 ’s Inner Classic. Diabetes is classically divided into Asking feels cold; reduced appetite; no taste patient feels hot; dislikes heat three types: upper, middle, and lower in mouth; desires warmth and touch; or touch; constipation; copious and clear urine; pressure scanty, dark urine; dry Xiao-ke. Each has characteristic relieves discomfort; scanty pale mouth; thirst symptoms. The upper type is charac- menses terized by excessive thirst, the middle 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 Integrative Medicine & Complementary / From Research to Practice 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 including pills, pow- with moxibustion. graphic recordings of blood flow has ders, plasters, and .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 , 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 have specific func- sions every 2–6 months.6 The cost for painful 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 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 (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 . 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 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 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 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 , 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 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 , 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 ry.7 It is generally recommended that 1Berman BM, Kaczmarczyk J, Swyers JP: clear contraindications to the use of patients eat a wide variety of seasonal Complementary and herbal specific herbs in certain populations, foods and avoid or minimize con- therapies for diabetes. J Assoc Acad Minor Phys such as pregnant women.13 sumption of sweets and fruits. Meals 10:10–14, 1999 158 Diabetes Spectrum Volume 14, Number 3, 2001 2 7

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