There are 2 types of diabetes mellitus. Type 2 is the commonest and is the one which is frequently seen in our clinics. Although people may not come specifically for their diabetes to be treated, it may be the background of their case when presenting with something else. Type 2 diabetes is characterised by a relative lack of insulin. Although the pancreas does produce some insulin, it is not in sufficient quantities for the person's needs. Conventionally, management through diet and exercise may need to be supplemented by oral medication. Insulin is rarely required. The presentation is chronic in nature with a gradual development of symptoms over weeks and months.
In Type 1 diabetes, on the other hand, the symptoms come on suddenly and strongly. It is much more an acute picture which can rapidly lead to deterioration in health and coma if not treated with insulin injections. This is collapse of pancreatic endocrine function with very little insulin produced by the patient themselves.
The term 'diabetes' is derived from the Greek word for a siphon as the key symptoms are of polyuria and water passing out of the body. 'Mellitus' derives from the Latin for sweet - hence Apis mellifica or honey bee. The primary difficulty in diabetes is with metabolising carbohydrates, particularly the refine varieties such as sugar. Insulin has the function of pushing glucose into the cell for use as energy and converting it into glycogen to be stored in the liver. When insulin levels fall, increasing amounts of glucose remain in the blood leading to the classical symptoms of thirst, hunger, excessive urination and eventually weight loss, drowsiness and, in extreme cases in Type 1 diabetes, coma and death. Before 1922, when insulin first began to be widely administered to diabetic patients, Type 1 diabetics would all die.
Traditionally, in Chinese medicine, diabetes mellitus is classified as thirsting and wasting disease. An excessive intake of sweet and/or greasy food stagnates in the Middle Jiao and leads to the generation of Heat. In addition, in some people heat can be generated due to emotional frustration and stagnation. Heat then damages the fluids and the exact clinical presentation depends upon the emphasis of the pattern. Upper Jiao patterns mainly manifest with excessive thirst, Middle Jiao problems leads to excessive hunger and Lower Jiao patterns show with excessive urination. In practice, there are usually mixtures of such symptoms.
In clinical practice in the West, we rarely see such Heat and thirsting/wasting either because diabetes mellitus is diagnosed very early on the basis of raised blood sugar levels or because people have already been treated with insulin or oral hypoglycaemic drugs.
As with all people we treat, we have to decide on a traditional Chinese medicine diagnosis. In many cases there are combinations of patterns, which include:
- Lung Heat
- Stomach Heat
- Kidney Yin Deficiency
- Spleen Qi Deficiency
- Damp Heat Accumulation in the Middle Jiao
The relevant treatment principles are guided by the precise pattern in the individual. However, you can see that a common theme is to tonify Spleen Qi, clear Stomach Heat and or Lung Heat and nourish the Yin.
An acupuncture protocol would include points such as:
- Zusanli (ST 36), Taibai (SP 3), Zhongwan (REN 12), Qihai (REN 6) to tonify Spleen Qi
- Zusanli (ST 36) with Neiting (ST 44) to Clear Stomach Heat with the addition of Fuliu (KID 7) to nourish Yin
- Chize (LU 5) to Yuji (LU 10) to clear Lung Heat
- Taiyuan (LU 9), Taixi (KID 3) and Shenshu (UB 23) to Nourish Yin
Of course, an added complication in the treatment of people with diabetes is the question of their medication. This is far more important in Type 1 diabetes where the person is dependent on insulin. Insulin is powerful and rapid acting. Monitoring of the insulin dosage is done by the person themselves based upon regular blood sugar readings. There is a risk of hypoglycaemia (low blood sugar) or hyperglycaemia (high blood sugar). It is important therefore, that we know how to recognise early symptoms of difficulty so they can be quickly addressed.
Aim towards blood sugar levels of:
- Between 4-7 mmol/l before meals
- Less than 10 mmol/l 90 minutes after a meal
- About 8 mmol/l at bedtime
Red flags (indications of a potentially serious situation)
Be aware of movement towards hypoglycaemia (low blood sugar) - levels less than 4 mmol/l and falling, hunger, tiredness, yawning which may eventually lead to confusion and coma.
Be aware of movement towards hyperglycaemia (high blood sugar) - levels more than 10 mmol/l and rising, thirst, frequent urination, hunger, tiredness, feeling ill, sensation of heat, drowsiness which may eventually lead to coma. The presence of ketones in the urine is an indication of a serious situation as ketones are toxic. Ketones appear when the body has insufficient glucose in the cell for metabolic processes so that fat is broken down. This occurs despite the presence of a high blood sugar level - the sugar is in the blood rather than in the cell.
When we treat people who take insulin, it is helpful to educate people about healthy diets and other methods to achieve a more balanced state of healthy. There are many good sources of information about diet, both from a Chinese perspective (see note 1) and dealing specifically with diabetes (see note 2).
We have to be careful to educate people that much, if not all, of the advice we give people may lead to reducing blood sugar levels. Unless the dosage of insulin is reduced, the person is at risk of hypoglycaemia. Adequate exercise, healthy diet with complex carbohydrates, reducing intake of carbohydrates, relaxation exercises, acupuncture and Chinese herbal medicine all tend to increase pancreatic function. This leads to a reduction in blood sugar which typically is most marked around 24 - 48 hours after treatment. This is not generally a problem as diabetics manage their own blood sugar control but it is important to inform people of this definite possibility.
As treatment progresses, it becomes clear over the course of weeks and months how people are responding to treatment. So-called 'brittle' diabetes, where the blood sugar levels are very variable, tends to settle down to a more stable picture. Insulin requirements will reduce and the person will feel better in themselves. It is rarely, if ever, the case that people can stop their insulin if they have been taking it for more than a few months but they frequently take a much reduced dosage of insulin. They can end up taking half to two thirds of their original total dose after some months of treatment. If holistic treatment is started early - either just before, or at the same time as, a diagnosis of diabetes mellitus there are cases of people coming off their insulin as their pancreatic function recovers. If insulin has been taken for more than a few months, then this possibility rapidly disappears.
In the case of Type 2 diabetes treated with oral medication, hypoglycaemia is much less of a risk as the drugs are less powerful than insulin and frequently act by encouraging the pancreas to produce more insulin. As people improve, the dosage can frequently be reduced slowly in conjunction with regular blood sugar monitoring and a number will be able to completely stop their medication.
Some years ago I treated a 26 year old man who had been diagnosed with Type 1 diabetes mellitus at the age of 10. He was taking a total daily insulin dose of 85 units of insulin throughout the day, a mixture of long-acting insulin taken at night and 3 doses of short-acting insulin before each meal based upon his blood sugar levels. His lifestyle was somewhat chaotic with recreational drug use, irregular eating, poor diet, smoking and drinking alcohol. His blood sugar in the mornings could be as high as 35 mmol/l. He would inject insulin intravenously on rising in order to control his blood sugar Intravenous use is only ever used in hospital in severe cases of hyperglycaemia requiring in-patient care. His pattern in Chinese medicine was primarily Spleen Qi Deficiency and I treated him with a combination of acupuncture weekly and a variation of Bu Zhong Yi Qi Wan. I never gave him advice about his lifestyle as I knew from a mutual friend that he was only coming to my clinic if I did not speak to him about his diet, smoking and so forth.
As the weeks went by, his blood sugars stabilised at moderate levels of less than 10 mmol/l, he felt better and his insulin dosage was gradually reducing. Eventually, he reached a stage where he felt able to change his lifestyle as his health improved and this supported his improvements in his health. He continued to take insulin as required according to his blood sugars but his general health was much improved. He was never a meditating, organic food enthusiastic yet he was happy with a diabetic state which was much easier to control.
Treatment of Diabetes Mellitus with Chinese Medicine by Bob Flaws, Lynn Kuchinski and Robert Casanas (Blue Poppy Press, 2002).
Also, check out www.bluepoppy.com for many articles on treating diabetes and its complications with Chinese medicine.
Note 1: Recipes for Self-Healing by Daverick Leggatt (Meridian Press, 1999), Prince Wen Hui's Cook by Bob Flaws and Honora Wolfe (Paradigm, 1985) and Chinese System of Food Cures by Henry Lu (Sterling, 1986).
Note 2: Dr Bernstein's Diabetes Solution by Richard K Bernstein (Little, Brown & Co., 2003) and Diabetes, Causes and Cure by Dr Johann Georg Schnitzer (Schnitzer, 1980)