Abstract 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 Weste rn medicine terms diabetes mellitus. This article will outline the ey concepts and therapies of TCM that play a role in the e!aluation and treatment of diabetic patients.
"iabetes is one of the most pre!alent chronic diseases in the #nited $tates. The morbidity and mortality associated with the disease is signi%cant and deri!es primarily from complications of persistent hyperglycemia. &ongstanding hyperglycemia has been shown to lead to !ascular complications in!ol!ing large and small blood !essels' such as arteriosclerosis' glomerulosclerosis' and retinopathy. "iabetic neuropathy' characterized by pain and paresthesias' is among the most freuent complications of longstanding' poorly controlled diabetes and is often associated with a reduction in physical acti!ity and with sleep disturbances. disturbances.'* Western or con!entional therapies for diabetes ha!e been geared toward regulating blood glucose with a combination of diet modi%cation' insulin and+or oral pharmacological agents' weight loss when appropriate' and exercise. ,lthough Western me dicine and Traditional Chinese medicine (TCM) share the diabetes treatment goals of reducing symptoms and pre!enting complications' their approaches to conceptualizing' diagnosing' and treating the disease are !ery di-erent. This article will outline the ey concepts and therapies of TCM that play a role in the e!aluation and treatment of diabetic patients.
Traditional Chinese Medicine
TCM is a system of healing that originated thousands of years ago. It has e!ol!ed into a well de!eloped' coherent system of medicine that uses se!eral modalities to treat and pre!ent illness. The most commonly employed therapeutic methods in TCM include acupuncture+moxibustion' acupuncture+moxibus tion' Chinese herbal medicine' diet therapy' mind+body exercises (/igong and Tai Chi)' and Tui 0a (Chinese massage).1 massage). 1 TCM !iews the human body and its functioning in a holistic way. 2rom this perspecti!e' no single body part or symptom can be understood apart from its relation to the whole. #nlie Western medicine' which sees to unco!er a distinct entity or causati!e factor for a particular illness' TCM loos at patterns of disharmony' which include all presenting signs and symptoms as well as patients3 emotional and psychological responses. 4umans are !iewed both as a re5ection of and as a n integral part of nature' and health results from maintaining harmony and balance within the body and between the body and nature.1 nature. 1 Two basic TCM theories explain and describe phenomena in nature' including human beings6 7in7ang Theory and the 2i!e 8hases Theory or 2i!e 9lement Theory. 7in and 7ang are complementary opposites used to describe how things f unction in relation to each other and to the uni!erse. They are interdependent:one cannot exist without the other'
and they ha!e the ability to transform into each other.1 The traditional 7in7ang symbol (2igure ) depicts the 7in (the dar side) 5owing into the 7ang (the light side) and !ice !ersa. The dots within each side symbolize that there is always a bit of 7in within 7ang and a bit of 7ang within 7in; there are no absolutes. ,ll physiological functions of the body' as well as the signs and symptoms of disease' can be di-erentiated on the basis of 7in and 7ang characteristics. The Chinese character for 7in originally meant the shady side of a slope. /ualities characteristic of 7in include cold' stillness' darness' inwardness' passi!ity' decrease' and downwardness. In contrast' the Chinese character for 7ang originally meant the sunny side of the slope' and ualities characteristic of 7ang include heat' mo!ement' brightness' outwardness' stimulation' excitement' increase' and upwardness.< Illnesses that are characterized by coldness' weaness' slowness' and underacti!ity are considered 7in (e.g.' hypothyroidism6 cold limbs' fatigue' slowed metabolism). Illnesses that manifest strength' forceful mo!ement' heat' and o!eracti!ity are 7ang (e.g.' acute infections with fe!er and sweating). The theory of 2i!e 8hases' Wu =ing' is a means of classifying phenomena in terms of %!e basic processes represented by the elements wood' %re' earth' metal' and w ater. There exists a dynamic balance and relationship among the elements such that if the balance is interrupted or destroyed' pathological changes may occur. The clocwise mo!ement of one element into the next (wood' %re' earth' and so forth) whereby one element generates' acts on' or promotes the following element' is referred to as the $heng cycle. The >e cycle represents an element acting on or controlling another element in a di-erent order ( 2igure *).1 Within the model of 2i!e 8hases' each element is associated with an organ. Wood is associated with the li!er' %re with the heart' earth with the spleenpancreasstomach' metal with the lungs' and water with the idneys. In addition' other phenomena' such as seasons' cardinal directions' weather' color' and emotions' are associated with each element. Within the TCM model' diagnostic information is gained by %nding out patients3 fa!orite season' color' and predominant emotion(s).
Key Concepts Within TCM Qi /i (pronounced ?chi@) is translated into 9nglish as !ital energy. It is de%ned in terms of function rather than as a discrete substance' and it is what animates us a nd allows us to mo!e and maintain the acti!ities of life. The origins of /i include ?congenital@3 (prenatal) /i:that w hich is inherited from our parents:and ?acuired@ /i:that which is incorporated from food and air. < Two maAor patterns of disharmony are associated with /i. "e%cient /i occurs when there is insuBcient /i to perform the functions of life. "e%cient /i may a-ect one or more organs or the entire body. If the latter occurs' then the patient may experience lethargy' fatigue' and lac of desire to mo!e. $tagnant /i refers to impairment of the normal mo!ement of /i through the meridians (see discussion below) and may result in aches and pains in the body. < Meridians Meridians are the channels or pathways through which /i is constantly 5owing and circulating throughout the body. There are * regular meridians and extra or ?curious@ meridians. The *
main meridians correspond to * maAor functions or ?organs@ of the body (such as li!er' idney' heart). The Chinese concept of organs corresponds only loosely to the Western concept. TCM associates speci%c functions' symptoms' emotions' colors' and tastes with each organ' whereas the Western !iew is limited primarily to function. /i must 5ow in the correct uantity and uality through the meridians and organs for health to be maintained. ,cupuncture' the insertion of thin' solid metal needles' is performed on or more of the 1D acupuncture points distributed along the meridians in order to regulate and promote the proper 5ow of /i.E Fther techniues may be used to stimulate acupuncture points' such as moxibustion' in which the herb ?moxa@ (,rtemesia !ulgaris) is used to warm the acupuncture point either abo!e or on the sin. ,pplied pressure (acupressure)' lasers' and magnets also may be used to stimulate acupuncture points. Jing Ging' usually translated as ?essence'@ is the substance that is the underpinning of all organic life. /i is responsible for the ongoing daytoday mo!ements and function of the body' whereas Ging can be considered an indi!idual3s constitutional maeup. ,ccording to TCM' Ging is stored in the idneys.< Shen $hen is considered to be the psyche or spirit of the indi!idual. $hen is the !itality behind Ging and /i in the human body. The three elements together:/i' Ging' and $hen:are referred to collecti!ely in TCM as the ?Three Treasures@ and are belie!ed to be the essential components of life.E Blood ,ccording to TCM' the maAor acti!ity of the blood is to circulate through the body' nourishing and moistening the !arious organs and tissues. "isharmonies of the blood may manifest as ?de%cient@ blood or ?congealed@ blood. If de%cient blood exists and a-ects the entire body' the patient may present with dry sin' dizziness' and a dull complexion. Congealed blood may manifest as sharp' stabbing pains accompanied by tumors' cysts' or swelling of the organs (i.e.' the li!er).< The ey organs associated with blood are the heart' li!er' and spleen. Fluids 2luids are bodily liuids other than blood and include sali!a' sweat' urine' tears' and semen. 2luids act to moisten both the exterior (sin and hair) and the internal organs. "isharmonies of 5uids may result in dryness and excess heat. The ey organs in!ol!ed in the formation' distribution' and excretion of 5uids are the lungs' spleen' and idneys. 1
Diagnosis in TCM
When e!aluating patients with a chronic illness such as diabetes' TCM practitioners tae a detailed' multisystem case history and supplement t his information with obser!ations that gi!e information about the state of the patient3s health. These obser!ations 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 uality of the pulse. Many practitioners will palpate along meridians to detect points of tenderness that may indicate a blocage in the 5ow of /i at that point.D Fne of the most common ways of di-erentiating symptoms and syndromes in TCM is according to the 9ight 8rinciples:four pairs of polar opposites6 7in and 7ang' Interior and 9xterior' Cold and 4eat' and "e%ciency and 9xcess. Characteristics of the 9ight 8rinciples are summarized in Tables and *.<
TCM Classication of Diabetes
The Chinese language includes two terms for diabetes. The traditional name' =iaoe' correlates closely with diabetes in most instances. =iaoe syndrome means ?wasting and thirsting.@ The more modern term' Tangniaobing' means ?sugar urine illness.@ Heference t o diabetes by the traditional term appears in the earliest texts' including the %rst medical text in Chinese history' Huang Di Nei Jing, or The Yellow Emperor’s Inner Classic. "iabetes is classically di!ided into three types6 upper' middle' and lower =iaoe. 9ach has characteristic symptoms. The upper type is characterized by excessi!e thirst' the middle by excessi!e hunger' and the lower by excessi!e urination. These types are closely associated with the lungs' stomach' and idneys' respecti!ely' and all three are associated with 7in de%ciency. ,t some point during the course of their illness' most people with diabetes manifest symptoms of all three types. ,ccording to TCM' =iaoe is attributed to three main factors6 improper diet (consuming large uantities of sweets' fatty or greasy foods' alcohol' and hot drins such as hot co-ee or tea)' emotional disturbances (stress' anxiety' depression') and a constitutional 7in de%ciency (fatigue' weaness' lethargy' pale complexion). To the Western ear' TCM diagnoses sound esoteric' e!en poetic. In the case of a person with diabetes presenting with symptoms of e xcessi!e thirst' the diagnosis can be described as idney 7in de%ciency along with lung 7in de%ciency and ?internal heat that consumes 5uids' thus bringing on wasting and thirsting.@
TCM Therapies
#nlie Western medicine' TCM is not concerned with measuring and monitoring blood glucose le!els in diabetic patients. Treatment is indi!idualized and geared toward assessing and treating the symptoms that compose patterns of de%ciency and disharmony. Acupuncture/moxibustion ,cupuncture and moxibustion traditionally ha!e been used in the treatme nt of diabetes to reduce blood glucose le!els and normalize endocrine function. Clinical and experimental studies ha!e demonstrated that acupuncture has a bene%cial e-ect on lowering serum glucose le!els.'J
, typical acupuncture treatment in!ol!es needling
The number of treatments for chronic conditions such as diabetes ranges from D to < sessions. This may be followed by ?tune up@ sessions e!ery *KD months. D The cost for the initial session is about E KEL' with the followup !isits costing DEKLL each. Thirdparty payment for complementary and alternati!e therapies !aries from state to state. $ome insurers' such as Nlue Cross Nlue $hield' co!er certain therapies for speci%c diagnoses only' i.e.' acupuncture for painrelated diagnoses. 2or an additional cost' a few insurance companies o-er a separate complementary medicine pacage that allows the insured to see complementary medicine practitioners at a discounted rate. ,uricular acupuncture (inserting needles into speci%c points on the ear) may be used alone or in conAunction with body acupuncture. ,ccording to TCM' the entire body is represented on the ear. 9xamination of the ears often re!eals surface irregularities' such as super%cial capillaries' scars' pitting' pimples' 5aing' discoloration' or swelling. #pon probing the auricle of the e ar with a rounded' blunt instrument the practitioner may disco!er tender areas that may correspond to the area of the patient3s pain or disturbance.L , sample auricular treatment for diabetes might include needling a master point' for example' $hen Men (a good point for almost all disorders)' along with the endocrine point' lung point (for thirst)' stomach point (for hunger)' idney and bladder points (for freuent urination)' and pancreas point (for increasing insulin secretion). 8eripheral neuropathy' one of the most common complications of type * diabetes' occurs most often in the distal extremities and typically a-ects the sensory' motor' and autonomic systems. ,cupuncture has been demonstrated to exert a bene%cial e-ect on neuropathic pain.* The e-ects of acupuncture' particularly on pain' are mediated in part by the release of endogenous opioids from the spinal cord' brainstem' and hypothalamus. In addition' it has been demonstrated that neurotransmitters' such as serotonin and substance 8' are released during acupuncture treatments. Increases in local blood 5ow and !asodilation and increased le!els of cortisol ha!e also been demonstrated.L , 1LLO increase in plethysmographic recordings of blood 5ow has been demonstrated in the digits of limbs stimulated with electroacupuncture.L , recent study of
Necause of poor peripheral circulation and slowed healing of sin infections and ulcerations' needling of the lower extremities in diabetic patients should be performed with extreme caution and sterile techniue. In general' howe!er' acupuncture appears to be a relati!ely safe form of treatment. ,n extensi!e worldwide literature search identi%ed only J1 ad!erse e!ents (including relati!ely minor e!ents' such as bruising and dizziness) o!er a Eyear period. There ha!e been approximately D reported cases of hepatitis N and case of 4IP transmission. In all of these cases' nondisposable needles were used.D Herbal medicine 4erbal medicine has been an integral part of TCM for more than *'LLL years. Many herbal formulations ha!e been de!eloped and are used in the treatment of diabetes. The Huang Di Nei Jing (Yellow Emperor’s Inner Classic )' which dates from the 4an "ynasty *LD N.C.K**L ,.".' listed 1 herbal formulations' J of which were patent medicines including pills' powders' plasters' and tinctures.* The sources of Chinese remedies are !aried and include plants' minerals' and animal parts.1 Chinese herbs ha!e speci%c functions (i.e.' w arming' heatclearing' eliminating dampness' and cooling) and can be classi%ed according to those functions. They are also classi%ed according to four natures (cool' cold' warm' and hot) and %!e tastes (sweet' pungent' bitter' sour' and salty).< 4erbs may be prescribed indi!idually or as part of a formula. 2ormulas promote the e-ecti!e use of herbs.1 , typical formula has four components' including6
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The Chief (principal) ingredient' which treats the principal pattern of disease'
*.
The "eputy (associate) ingredient' which assists the Chief ingredient in treating the maAor syndrome or ser!es as the main ingredient against a coexisting syndrome'
1.
The ,ssistant (adAutant) ingredient' which enhances the e-ect of the Chief ingredient' moderates or eliminates the toxicity of the Chief or "eputy ingredients' or can ha!e the opposite function of the Chief ingredient to produce supplementing e-ects' and
<.
The 9n!oy (guide) ingredient' which focuses the actions of the formula on a certain meridian or area of the body or harmonizes and integrates the actions of the other ingredients.1 4erbal prescriptions for diabetes are formulated or prescribed based on the patient3s predominant symptoms. 2or instance' a patient presenting primarily with e xcessi!e thirst (lung 7in de%ciency) might be gi!en a single herb' such as radix panacis uinuefolii; or a combination of herbs in a patent formulation such as yu chuan wan' which is used in general to treat diabetes of mild to moderate se!erity and speci%cally to treat excessi!e thirst due to 7in de%ciency'* and ba wei di huang tang (?eightingredient pill with rehmannia@)' which was originally used to treat people exhibiting weaness' f atigue' and copious urine soon after drining water.1 $ome of the most commonly used herbal substances for diabetes in TCM include6
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8anax ginseng (>orean ginseng)' which has a long history of use as a hypoglycemic agent. ,t least %!e constituents of this herb ha!e been shown to exert hypoglycemic e-ects. In one study' treatment with ginseng lowered blood glucose le!els and impro!ed mood and psychological performance as compared with placebo. Hecommended dosage is LLK*LL mg+day.<
*.
Momodica charantia (balsam pear)' which is dried' powdered' and made into pills. , dosage of g+day has been shown to reduce blood glucose. E
1.
&agenaria siceraria (bottle gourd)' gi!en as a decoction or pills. The recommended dose is 1 g+day. This' too' has been shown to reduce blood glucose le!els .E
<.
8sidium gnaAa!a' taen in the form of fresh lea!es or as an infusion and drun as a tea. The dosage is J g+day. It acts to reduce blood glucose le!els. E The abo!e herbs do not appear to increase insulin le!els' but rather enhance carbohydrate utilization.E 8atients should ha!e their type of diabetes and any other diagnoses con%rmed before initiating any herbal treatment. In a ddition' one should %rst ascertain the credibility of the herbal therapist by inuiring about where and for how long the person recei!ed training and about membership in herbal associations such as the ,merican 4erbalists Quild. To become members' herbalists must submit three letters of reference from other professional herbalists' a description of their training' and an account of at least < years of experience woring with medicinal herbs. ,s part of their training' TCM practitioners learn about the proper use of herbals. Many Chinese herbs and formulations ha!e been used safely for centuries in the hands of trained TCM practitioners. It is important to recognize' howe!er' that data on drugherb interactions are scarce' and there are clear contraindications to the use of speci%c herbs in certain populations' such as pregnant women. 1 "iscontinuing con!entional medications in fa!or of herbal formulations may lead to serious complications such as signi%cant hyperglycemia' and combining con!entional hypoglycemic agents with herbal preparations without proper monitoring could lead to hypoglycemia. The 2ood and "rug ,dministration (2",) does not regulate herbs' minerals' animal products' and patent formulas that come into the #nited $tates from China. 4erbal products are considered dietary supplements according to the "ietary $upplement and 4ealth 9ducation ,ct ("$49,) of JJ<; therefore' the manufacturers do not need 2", appro!al or e!aluation for safety' purity' and eBcacy before bringing their products to maret. There ha!e been reports of some formulas imported from China containing hea!y metals such as lead and mercury and of others being deliberately adulterated with con!entional Western pharmaceuticals' such as corticosteroids' antiin5ammatory agents' and benzodiazepines. D Diet therapy ,ccording to TCM' diet plays an important role in maintaining health and treating disease. In the TCM paradigm' foods are !alued and prescribed for their energetic and therapeutic properties rather than solely for their chemical maeup. ,ttention is paid to the uantity' uality' method of preparation' and time of food intae' as well as to the patient3s body type' age' !itality; geographic location; and seasonal in5uences.
Necause TCM de%nes diabetes as a disease characterized by 7in de%ciency and excess internal heat' an example of a dietary prescription would be to consume spinach' which is cooling' ?strengthens all the organs' lubricates the intestines' and promotes urination.@ , recommendation might be to boil tea from spinach and drin cup three times+day. Fther foods considered to be cooling and bene%cial for diabetes include !egetables and grains' such as celery' pumpin' soybeans (i.e.' tofu' soymil)' string beans' sweet potato+yam' turnips' tomato' wheat bran' and millet. 2ruit remedies' which act in speci%c therapeutic ways' include crab apple' gua!a' plum' strawberry' and mulberry. It is generally recommended that patients eat a wide !ariety of seasonal foods and a!oid or minimize consumption of sweets and fruits. Meals should be smaller' eaten more freuently' and eaten at regular times each day. Qigong /igong (pronounced ?chi gong@) is literally translated as ?function of /i.@ It emphasizes the connection between the mind and body. It is a meditati!e method that consists of breathing techniues that can be combined with body mo!ements in order to regulate' harness' and enhance /i. /igong is used as a means of promoting health' healing' spiritual growth' and o!erall wellbeing. While /igong is not typically used as a maAor treatment modality for diabetes' it has been found to be a !aluable adAuncti!e therapy for this condition. There are speci%c /igong exercises for diabetes.E Tui a Tui 0a is a traditional form of Chinese massage that uses hand manipulations' such as pulling' neading' pushing' and grasping to stimulate acupuncture points and other parts of the body to create balance and harmony in the system. It can be used e-ecti!ely in lieu of acupuncture in patients who ha!e an a!ersion to needles' particularly pediatric patients. 1
Conclusion
TCM does not o-er a cure for diabetes' but instead aims to optimize t he body3s ability to function normally. There is still a great need for more and better research on the eBcacy and safety of both Chinese herbals' which are being used along with or in lieu of Western pharmaceuticals' and acupuncture in the care of diabetic patients. 8atients' TCM practitioners' and physicians who choose to integrate the two forms of care must all recognize the importance of careful monitoring of blood glucose le!els' as well as monitoring for potential side e-ects such as drugherb interactions. ,s always' in seeing to integrate di-erent traditions and forms of healing' we are seeing to o-er patients the safest' most e-ecti!e care possible. Hemaining open to alternati!e forms of care and educating oursel!es about the safety and eBcacy of these modalities can bene%t us al
