The TCM of diabetes
Jackie, 53, always felt tired and had been putting on weight steadily since her early 40s. When she first came to see me two years ago, her doctor had told her that her blood sugar levels were too high, too often. Jackie was now about to follow in the footsteps of her mother and commence a lifetime of medication. She was overweight. She had a long commute to work every day, leaving little time for exercise. Her job, looking after computer systems in a hospital, is stressful. She arrives early and leaves late. Surrounded by people in ill health all the time, Jackie knows she is doing all the wrong things. Her tiredness means she often reaches for a sugar fix or chocolate bar to push her along in the afternoon. But she is too busy to stop. When Jackie does stop for a moment to reflect, and for a few days makes good lifestyle choices such as eating regular, freshly prepared meals and taking a little exercise, she feels so much better, but she can’t seem to sustain it.
The consequences for Jackie of not keeping her blood sugar under control are serious. None of the drugs on the market can stop diabetes. It’s progressive and eventually these drugs fail to maintain normal glycaemic control. Doses are increased, another drug is added. I remind Jackie that about 60 to 70 per cent of people with diabetes end up with some form of nervous system damage. The results of such damage might be numbness in the hands or the feet, carpal tunnel syndrome, or her vision might diminish. If she really lets things go, it can progress to amputation or blindness. Sadly, she is now two to four times more likely to have a stroke than someone else her age. However, right now Jackie doesn’t need a lecture because, in the midst of all this, her marriage is unraveling and stress makes blood sugar even more erratic.
Rarely do my diabetic patients comprehend that this disease can have devastatingly serious consequences. Their experience is that, at the moment, they feel tired from time to time, maybe occasionally there’s some annoying thrush or frequent urination. In traditional Chinese medicine, all of these signs would be cause for concern. A Chinese medicine practitioner would start the patient on a course of treatment before there was any evidence of elevated blood sugar. Tiredness is a sign the body is out of balance, as are being overweight and thrush. Usually a Chinese medicine treatment aims to balance these symptoms with an individualised herbal formula, perhaps some acupuncture, always some dietary advice, and always some advice “to slow down, reduce your stress, do some tai chi”. In China, patients take this advice very seriously and are admonished vehemently if they return to their practitioner and have not made diet and lifestyle changes.
Usually a Chinese medicine treatment aims to balance these symptoms with an individualised herbal formula, perhaps some acupuncture, always some dietary advice, and always some advice “to slow down, reduce your stress, do some tai chi”
In ancient times, Jackie would pay her Chinese medicine doctor while she was well. She would have regular herbs, acupuncture, and follow sage advice. If she got sick, one could assume the Chinese medicine doctor had not done his job properly. He would be obliged to treat her for free until she was well again. This model of preventive medicine is described in an ancient text of Chinese medicine. The Yellow Emperor’s Classic of Chinese Medicine states, “When a disease has already broken out and is only then treated, would that not be just as late as to wait for thirst before digging a well, or to wait to go into battle before casting weapons?” Preventing disease was fairly high on an ancient TCM doctor’s list of priorities. He would earn little if his village was unwell. Really understanding causes of disease, identifying early signs and being able to use herbs, acupuncture, diet and exercise to prevent disease was a wise and financially smart thing for a Chinese medicine doctor to become very good at.
A disease with signs and symptoms similar to our modern-day diabetes first appeared in an ancient Chinese medicine text around 475-221 BCE. Remarkably, the causes of the disease described in this ancient text are very similar to what we, in the west, identify as the causes. “The typical patient who suffers from this disease is often wealthy. You may ask them to refrain from a rich diet, which they may resist.” In yet another reference, “This person must [eat] many sweet, fine [foods] and too many fats.” Other causes of diabetes in the ancient texts were related to family history and mood, particularly anger and stress. Too much work and insufficient rest, a lack of exercise, and too much “stillness” also make appearances in ancient and recent Chinese medicine texts as some of the stepping stones on the journey to diabetes.
A TCM diagnosis
In modern-day Chinese medicine hospitals and in clinics in the west, we still rely on these ancient classical texts but also on modern research to guide our treatment. Specific treatment is guided by the full range of presenting symptoms of each individual. On your first visit to their clinic, a TCM practitioner will enquire about all manner of things, such as do you like your drinks hot or cold? Do you have much thirst? Is winter your favourite season? Have you been feeling sad, happy or angry lately? Do you wake during the night? At what time?
You may wonder what this has to do with your blood sugar levels. We diagnose by looking, hearing, smelling (yes, smelling, like your breath, for example), asking, touching and palpating in such a way that extends well beyond what is considered typical in western medicine.
Facial colour and complexion reflect the health of the inner organs. The eyes reveal the health of shen, or the spirit. Feeling by palpation along the Chinese meridians or channels guides clinical reasoning and diagnosis. All of these clinical signs and symptoms are drawn together to identify a pattern of imbalance or disharmony. Any disease may have numerous patterns of disharmony, depending on the individual’s manifestation of the disease. A Chinese medicine practitioner tends to the individual, not the disease.
In clinic, there may be two people presenting with the same (western) medical diagnosis of pre-diabetes, but they may have a different clinical presentation, leading to a different TCM diagnosis. One may be overweight with muscle aches and tiredness, while the other might have a wiry body, experience sweating on the hands and feet and a dry mouth. In TCM, these would be two different syndromes: Spleen Qi Deficiency with Damp, and Kidney Yin Deficiency respectively. Each pattern will need different herbs and dietary advice. As time passes, different medicinals become appropriate. Confused? Let’s go back to Jackie.
Remember, Jackie is overweight and on further questioning I discover she often feels heavy in the arms and legs, like it’s an effort to lift them. Her digestion is poor. She often feels bloated and has loose stools. Her tiredness is much worse in the morning. This isn’t helped by her poor sleep; she tosses and turns, her thoughts buzzing between her difficult marriage and stress at work. She has very little thirst, frequent urination, and has recurrent vaginal thrush. When I look at her tongue, the body is pale and has teeth marks along the edges. There is a slightly thick yellow-tinged coat on her tongue. I check her pulse and in Chinese medicine terms it feels “soggy”.
Facial colour and complexion reflect the health of the inner organs. The eyes reveal the health of shen, or the spirit
The absence of thirst indicates a cold or damp condition. Her tiredness in the morning, thrush and heavy limbs indicate “dampness”. Her poor digestion suggests her qi is deficient. In Chinese medicine terms, the “spleen” is weak. So put this all together and we arrive at a diagnosis of “dampness” and “heat” damaging the Spleen. Unlike western medicine, the Chinese medicine “spleen” is a function, not a place. Think of the “spleen” as the minister for agriculture, overseeing production and distribution of farm resources, supplying the nourishment that sustains you. It is responsible for transformation and represents the efficiency of your digestion and metabolism.
When it is out of balance, the “spleen” becomes congested. This may manifest as bloating, heaviness, tiredness, your mind becoming easily distracted, and your memory will be poor. There may be swelling in the feet or under the eyes. When you eat heavy, damp foods, over-eat, consume too many cold, sweet foods, do too little exercise or over-use antibiotics, you risk weakening or damaging the “spleen”. Long before signs and symptoms appear to western medical eyes and the diagnosis of diabetes is chillingly delivered, the Chinese medicine practitioner would have been taking action to strengthen your spleen. Diet and lifestyle are important in both western and Chinese medicine, but with some very different perspectives.
Diet and lifestyle
There is much discussion about what to eat in Chinese medicine and specific recommendations depend on the diagnosis made by your Chinese medicine practitioner. Generally, to strengthen digestion, eat foods that are warming, such as onion, leek, ginger, cinnamon, fennel and cooked vegetables, while reducing cooling foods such as raw vegetables, citrus fruits and dairy foods.
The timing of when you eat is important too. As night becomes day, qi moves through different organs and channels in your body. The qi will reach its peak in each organ and meridian for a two-hour block throughout the day. The large intestine, stomach and spleen are at their peak between 5am and 11am. This is when your body is ready to receive, digest and transform your breakfast. Western science proposes that the body’s circadian clock dictates the timing of daily expression of metabolic genes in the liver. Chinese medicine implies that it is the timing of our food intake that stimulates this metabolic expression. Recent animal experiments support the Chinese perspective: the times at which eating and fasting occur each day have a huge impact on metabolism. The researchers in this study went so far as to say that this may explain why shift workers are more prone to metabolic syndrome, diabetes, high cholesterol levels and obesity. Other studies have shown that having breakfast gives you the best chance of regulating your weight, avoiding diabetes, and managing your energy levels through the day.
Not only should you follow your daily body clock, but your seasonal one also. In each season, qi is at its peak in one internal organ. In winter, you should nourish the kidney energy by taking warming foods and drink. In general, more food and nourishment is needed in the spring and summer. The simplest way to respond is to eat seasonal, local food.
Taking part in a program of qigong exercise may be beneficial for people with diabetes. Gong means to work or to train, so qigong may be translated as to train one’s qi. In an Australian study, people with elevated blood glucose levels who were randomised to a qigong exercise intervention had better body weight, waist circumference and leg strength. In addition, indicators of diabetes control (HbA1c, insulin resistance and fasting blood insulin) were found to have improved significantly more in the qigong group.
As well as recommendations about diet and exercise, the Chinese medicine practitioner preventing or treating diabetes will prescribe herbs and may offer acupuncture.
Most manufactured drugs have been developed from medicinal plants. Metformin, also known as diformin, the current first-line treatment for impaired glucose tolerance (IGT) and type-2 diabetes, is derived from Galega officinalis (French lilac). Galega officinalis is rich in guanidines, which have hypoglycaemic effects. Hundreds of herbs and herbal formulas have been developed within Chinese medicine for the treatment of type-2 diabetes over the last 2000 years. It is estimated that more than 200 species of plants alone exhibit hypoglycaemic properties, including many common plants such as pumpkin, celery and bitter melon. A review of several clinical trials of people with prediabetes found that those taking Chinese herbal medicines, combined with lifestyle modifications, were more than twice as likely to have their fasting plasma glucose levels returned to normal levels compared to those who made lifestyle modifications only. Fourteen herbal medicines are officially approved as “off the shelf” treatments for diabetes in China.
From a western science perspective, type-2 diabetes can be prevented or delayed by three types of interventions:
- Interventions that limit fat accumulation in the body (less obesity = less insulin resistance)
- Interventions that uncouple obesity from insulin resistance (less insulin resistance = less beta-cell failure)
- Interventions that directly preserve beta-cell mass and/or function (better beta-cell function = less diabetes)
The beta-cell is one of the cells in your pancreas that is under extra stress in diabetes. The beta-cell is one of the body’s main producers of insulin, which helps to bring down high blood sugar. When we look at six herbs commonly used for diabetes in Chinese medicine, we find they affect insulin resistance, beta-cells and lipid profiles in ways that are quite consistent with a western science approach.
Huang Lian, or Coptis chinensis, grows throughout China. Berberine constitutes the most abundant active ingredient in the dried herb. Huang Lian appears to exert a protective effect on beta-cells. It is being studied by the Garvan Institute for Diabetes at St Vincent’s Hospital, where they found that berberine and metformin (one of the most common pharmaceutical treatments for prediabetes and early-stage type-2 diabetes) share a number of features in common, such as improving insulin sensitivity. Other studies have shown that Huang Lian might also produce favourable results for cholesterol, acid regurgitation and diarrhoea. A word of warning: you probably won’t want to brew this herb in a cup of tea. It’s among the bitterest of all the herbs in the Chinese Materia Medica, but you will probably find it as the main ingredient in some off-the-shelf products.
Pu’er is a dark fermented tea which can help treat the metabolic syndrome which precedes type-2 diabetes. This tea, which is much more pleasant than Huang Lian, has been shown to reduce BMI, blood lipids, blood sugar, immune and inflammatory markers and oxidation status.
A daily dose of cinnamon is looking like a good way to improve blood sugar levels in people with type-2 diabetes, according to US- and UK-based research. Results show a significant reduction in levels of glycated haemoglobin (a long-term measure of blood sugar levels) in the cinnamon group, compared with an increase in the placebo group. Try one teaspoon of organic ground cinnamon on your porridge in the morning.
Di Huang (Rehmannia glutinosa) is cultivated throughout China as a medicinal herb and is widely used in Chinese herbal formulas for diabetes and prediabetes.
Huang Qi, also known as astragalus or milkvetch root, is perhaps better known in the west as an immune tonic. It is indigenous to China, Mongolia, Korea and Siberia and features in many anti-diabetic and hypoglycaemic formulas. It has a known effect on insulin and has a protective effect on beta-cells of the pancreas.
Jiang Huang (turmeric)
Jiang Huang, commonly known as turmeric, is native to southern Asia and cultivated extensively in India and China. More than 30 Curcuma species (Zingiberaceae) are found in Asia, where the tuber and the rhizomes of these plants are used as both food and medicine. Jiang Huang is thought to regulate diabetes in several ways: reduction of inflammation, reduction of blood glucose levels, modulation of lipid profiles, prevention of pancreatic β-cell death, and increasing insulin.
A word of advice before you stock up on these individual herbs. In traditional Chinese medicine it’s unusual to prescribe just one herb. Most treatments are comprised of complex formulas of a number of different herbs and rely on a synergy of these herbs.
Treating diabetes, metabolic syndrome and pre-diabetes will often involve acupuncture, either to supplement other treatments or as a treatment on its own. The specific acupuncture points used will depend on your individual pattern of qi flow and blockages.
In a hospital in Beijing where I spent some time studying diabetes, I saw many other types of treatment for diabetic neuropathy and diabetic ulcers. Often the ulcers would be treated, very effectively, with a decoction of herbs applied externally. Treatment for neuropathy would often involve acupuncture and a herbal tea to drink that encouraged circulation to the extremities.
Generally, to strengthen digestion, eat foods that are warming, such as onion, leek, ginger, cinnamon, fennel, and cooked vegetables, while reducing cooling foods such as raw vegetables, citrus fruits and dairy foods
Chronic diseases are multifactorial by nature, so an approach that focuses only on the endpoint pathology (in this case, hyperglycaemia) is doomed for failure. One of the great strengths of Chinese medicine is its apparent ability to hold disease processes at bay by promoting the general health of the individual. We are all different. We all respond differently to our environment and our patterns of disharmony are unique. The precise herbs, diet, exercise and acupuncture regime that will help a person’s diabetes will be different to that which will help another person. You should always look for a registered Chinese medicine practitioner for proper diagnosis and advice before self-prescribing. A list of these practitioners can be found on the Australian Acupuncture and Chinese Medicine Association website.
Taking the cure
Different herbs and herbal compositions can be used to treat the different patterns of disharmony, and standard formulations are often modified to take into consideration other symptoms, such as sleep disturbance or foggy-headedness. In Jackie’s case, her elevated blood sugars were accompanied by a poor digestive system and loose, frequent stools. Her sleep is also not restful. I am able to add and subtract herbs and give advice to address these other symptoms while helping her primary goal of reducing her blood sugar.
I see many people like Jackie. When it comes to preventing diabetes, the best advice is to eat well and exercise regularly, but for many of us, changing our lifestyle for the better can be difficult to achieve and maintain. For months or years, you might find yourself dismissing dietary and exercise advice from your healthcare professional as slowly your blood sugar levels rise and rise. Then suddenly faced with “I think it’s time to start you on medication”, you take action. This could involve a well-intentioned gym membership and someone might mention trying some herbs and acupuncture. This is when you are likely to appear at a Chinese medicine clinic.
Over the course of six months, Jackie now has good digestion and sleeps soundly. Her stress levels are down and her blood sugars are improving. Jackie struggles to maintain a good diet and regular exercise and she still needs to take her herbs. Perhaps if I make the herbal concoction taste really bad she’ll find the incentive to permanently take on the lifestyle changes, and then be able to give up the herbs.
“Health and wellbeing can be achieved only by remaining centred in spirit, guarding against the squandering of energy, promoting the constant flow of qi and blood, maintaining the harmonious balance of yin and yang, adapting to the changing seasonal and yearly macrocosmic influences, and nourishing one’s self preventively. This is the way to a long and happy life,” — The Yellow Emperor’s Classic of Medicine
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