AP and the Digestive / Gastrointestinal Tract SPLEEN/PANCREAS/DIABETES (1/2)
(see immunity-blood diseases also)
Bodnar_PN; Peshko AA (1992) [The AP reflexotherapy of diabetes mellitus patients]. Vrach Delo May 5:12-16.
Chen_D; Gong D; Zhai Y (1994) Clinical and experimental studies in treating diabetes mellitus by AP. JTCM Sep 14(3):163-166. Provincial Inst of TCM and Pharmacy, Jilin Province, PRC.
Choate_C1 (1996) Diabetes mellitus from the perspectives of WM and TCM: Part 1. Adapted from WWW (Acupuncture.com). Clinton Choate LAc; e-mail: CHAOTE1@aol.com.
Western clinical observations
Background
Because of its frequency, diabetes probably is the most important metabolic disease. It affects every cell in the body, and the essential biochemical processes that go on there. Diabetes has been known as a Med problem since antiquity, one which ranks 8th as a cause of death in USA. The name which was originated by Aretaeus (30-90 AD) came from the Greek words meaning "siphon" and "to run through" and in Med signifies the chronic excretion of an excessive volume of urine.
The cause of spontaneous diabetes mellitus, hereafter referred to as DM, is not known. The fundamental cause, however, is a relative or complete lack of insulin, the hormone produced by Beta cells in the pancreatic islets of Langerhans, which is necessary for the metabolism of carbohydrates. Since we know that the ways that the body derives Nutritive Qi (energy from food) (fats, carbohydrates, proteins) are intermingled, any problem in carbohydrate metabolism will necessarily affect the metabolism of protein and fat as well.
Carbohydrate is the active fuel of the body and is ordinarily the main source of energy of the tissue cell. It is utilized chiefly by the body in the form of glucose and is circulated to the tissues by the blood which keeps it in constant supply. The quantity of glucose in the blood seldom exceeds 160 mg/100cc of blood shortly after food sugar has been absorbed nor seldom falls below 60 mg/100cc during fasting.
In the blood, glucose apparently freely enters certain cells such as those of the CNS but requires the help of insulin to enter most cells at a normal rate. Insufficient production of pancreatic insulin for the metabolism of food sugars and starches produces the diabetic condition. In the normal digestion, food sugars and starches (carbohydrates) are changed into glucose. This is stored in the form of glycogen (animal starch) in the liver and muscles for later use as a body fuel, at which time it is reconverted into glucose. Insulin is the essential hormone for both the storage and conversion of glucose. The metabolic failure characteristic of DM may occur because the body produces too little insulin, or because of a faulty chemical reaction, or a combination of both. The result of the disturbed glucose metabolism causes an abnormal accumulation of sugar in the blood stream and the diabetic condition.
Symptomatology
DM is characterized by 3 Syndromes: polydipsia (excessive thirst), polyphagia (excessive hunger) and polyuria (excessive urination). Lab findings reveal high blood sugar and glucose in the urine. Excessive ketone bodies appear in the blood and urine as the metabolic derangement worsens. Their accumulation produces acidosis which, if not counteracted, can cause coma and death.
Much has been written on the possible etiology of diabetes, most of it speculative. Also, knowledge of the etiology is not particularly helpful in the clinical management of the disease and will not be considered in detail here. Most ideas can be classified under one of the following categories: heredity, endocrine imbalance (hyperpituitarism, etc), dietary indiscretion, sequelae of infection and severe and continued psychic stress. A probable genetic tendency towards diabetes would suggest the wisdom of keeping a close check on close relatives.
The other hypothesized etiologies all stem from factors known to aggravate the disease such as infections, obesity, and psychic stress. From a practical point of view, therefore, it is wise for diabetics or potential diabetics to control their weight, to avoid as much psychic stress as possible and to treat any infections promptly, but who shouldn't?.
Presenting symptoms
The clinical manifestations of diabetes in the order in which they usually appear are:
1. frequent copious urination
2. excessive thirst
3. rapid weight loss
4. excessive hunger
5. drowsiness, fatigue
6. itching of genitals and skin
7. visual disturbances
8. skin infections.
In juveniles, 50-75% of the earliest symptoms noted are increases urination, thirst and hunger. Physical findings in adults are mostly attributable to complications; the first sign of the disease may be a dermatological, circulatory, neurological or visual complication.
Lab diagnosis
Lab diagnosis of diabetes depends on finding glucose in the urine concurrently with an elevated blood sugar. Appearance of glucose in the urine depends on its level in arterial blood, the rate of glomerular filtration, and the efficiency of tubular resorption in the kidney. Thus, kidney thresholds for glucose vary widely, both in normal persons and in diabetics. Glycosuria may also occur incidental to emotional stress, systemic infection, or due to hyperthyroidism.
In the Second Edition of the Diabetics Guide for the Physician published by the American Diabetes Assoc, the upper limit of normal for venous blood sugar levels is 130 mg/100 ml in the fasting state and 200 after a meal. Normal fasting level in venous plasma is 60-110 mg/ml, increasing by circa 2 mg/100 ml/decade after age 30. In Type I, or juvenile diabetes, insulin secretion is low. Insulin is the message carrier that orders blood sugar to go down. In juvenile diabetes, there isn't any message, so again the blood sugar rises. In Type II (maturity-onset diabetes, NIDDM) insulin secretion is plentiful; many Type II diabetics have too much insulin, but the message is not received and the blood sugar rises. Blood glucose values above normal, in the absence of complicating illness, drugs, or stress, usually indicate diabetes. After meals, values of 250-350 mg/100cc are not unusual in moderately severe DM. Some mild diabetics will have normal fasting blood sugar values and values in the diabetic range only after meals. Occasionally very mild cases will have values within normal at both times and the diabetic tendency will be evident only when these persons are required to handle more than an ordinary amount of carbohydrate. The Glucose Tolerance Test (GTT) was conceived to test such patients by giving a large amount of glucose or food at one time to measure the adequacy of their islet tissue.
Complications or sequelae of diabetes
Sometimes a complication of diabetes may give a clue to the recognition of the disease. The principle complications or sequelae associated with diabetes are retinopathy, neuropathy, nephropathy, and arteriosclerosis. Whether these are the unavoidable consequences of the existence of the diabetic state over a period of time or whether they may be influenced by the degree of control of the diabetes is still a question. Complications do, however, create trouble for the diabetic and may when they are vascular disorders, reduce life expectancy.
Since the discovery of insulin nearly 70 yr ago, the patterns of morbidity from diabetes have changed. The major cause of death were diabetes ketoacidosis and infection, whereas they are now the microvascular and cardiovascular complications of diabetes, kidney failure and MI (myocardial infarction). These complications reduce the life expectancy of a newly diagnosed insulin dependent diabetic by circa 1/3. The basis of managing diabetes in the 80s is an improvement in the life-style of the diabetic and prevention of complications responsible for morbidity and mortality in diabetes.
Choate_C2 (1996) Diabetes mellitus from the perspectives of WM and TCM: Part 2.
Retinopathy
Eye lesions typical of diabetes involve the veins and capillaries of the retina. Cataracts, associated with early diabetes, seem more frequent in young diabetics; senile cataracts are as frequent in non-diabetics. It usually takes between 10-13 yr for diabetic retinopathy to develop and it is present in some degree in most diabetics who have had the disease for 20 yr. However, the diabetics who develop impaired vision, marked impairment affects only circa 50% and only circa 6% go blind.
Neuropathy
Diabetic neuropathy, which includes pain, paraesthesias and myalgias, is largely peripheral neuritis. The femoral nerve is commonly involved, causing symptoms in the legs and feet, although nerves in the arms, abdomen and back may also be affected. Pain is the chief symptom which tends to worsen at night when the patient is at rest and is relieved by activity. It is aggravated by Cold. Paraesthesias are a common accompaniment of the pain. Attendant cramping, tenderness and weakness of the muscle may occur but atrophy is rare.
Involvement of the ANS may cause such signs as reduced or absent perspiration, reduced vasomotor and pilomotor function, dependent edema, sever edema, severe constipation or nocturnal diarrhoea, sexual impotence, urinary and faecal incontinence, bladder atony and paralysis.
DM is probably the single most common disease associated with erectile failure. As an erection involves all levels of the nervous system, from the brain to the peripheral nerves, lesions anywhere along the path may cause erectile failure. It has been estimated that close to 50% of diabetic males have some degree of erectile dysfunction since diabetes is a metabolic disease with vascular and nervous system complications. The diabetic condition may affect the blood and nerve supply to the penis with the consequent neurogenic impotence.
As diabetes is controlled, neuropathies usually improve, but it may take several wk or mo to show maximal benefit in severe or chronic changes. Paradoxically, there may be a transient aggravation of symptoms with regulation of the disease; the reasons for this are unknown. A high protein intake and supplementary vitamin B-complex, including vitamin B12 1000 mg/d, may be helpful.
Arteriosclerosis
The diabetic state is associated with earlier and more severe vascular changes than occur normally at a given age. HT-vascular-KI disease is the leading cause of death among diabetics. The diabetic appears generally subject to arteriosclerotic changes, but the heart, brain and leg arteries are most often affected by occlusive lesions. The incidence of coronary occlusion in patients with clinical diabetes has been estimated at from 8-18%.
Arteriosclerosis obliterans in the lower extremities may produce such sensations as disturbances in sensation, decrease in muscular endurance, intermittent claudication on effort (cramping of calf muscle) and finally gangrene. Diabetic gangrene usually involves the toes, heels or other prominent parts of the feet and is precipitated by trauma, infection or extreme in temperature.
The aetiology of disease of the large vessels is multifactorial in the diabetics as well as in non-diabetics; lipoprotein metabolism, hypertension, physical activity, obesity, cigarette smoking, stress, personality, genetic and racial factors all play a part. As well as these general factors operative in diabetes, attention has been paid to specific metabolic disorders which could theoretically increase the severity or rate of formation of atheroma in diabetes. Epidemiologic data show no increased risk from diabetes independent of hypertension, cigarette smoking and hyperlipaemia. However, it is possible that hyperfibrinogenaemia, decreased fibrinolysis, abnormalities in platelet adhesiveness and platelet dysfunction, changes in prostaglandin metabolism and the vessel wall, may all play a part. Insulin depletion itself may influence the progression of atheroma through synergistic mechanisms involving hyperlipaemia, altered platelet behaviour and abnormalities in the arterial wall.
Nephropathy
Nephropathy is a common and important effect of diabetes, one which takes precedence over heart disease as a cause of illness and death in young diabetics. As with eye changes, kidney damage shows wide variation in type and degree. Nephropathy is less frequent than retinopathy; when it occurs it also is an effect of long-standing diabetes.
In one study, 50% of 200 juvenile diabetics who survived 20 yr after onset had evidence of kidney disease. The typical nodular lesions of the glomeruli did or did not cause clinical symptoms, depending on the number of glomeruli involved. In another study, most patients had hypertension; 2/3 had albuminuria, but the fully developed nephrotic Syndrome of hypertension, proteinuria and edema occurred in <10% and kidney function was impaired in very few of those patients.
Ketoacidosis
One of the by-products of fat metabolism is the formation of chemical compounds called ketones. When ketone bodies are excessive, diabetic acidosis results, leading to possibly fatal diabetic coma. The possibility of ketoacidosis is suggested by: confusion or coma, the patient almost always appearing extremely ill; air hunger, an attempt to compensate for metabolic acidosis; acetone odour (fruity) invariably on the breath; nausea and vomiting almost always present; abdominal tenderness which may mimic viral gastroenteritis; extreme thirst and dry mucous membranes; weight loss; diabetic history, present in circa 90% of cases.
Before the discovery of proper treatment by insulin and other iv injections, acidosis was the chief cause of death among diabetics.
Hypoglycemia
If insulin levels are too high relative to glucose, blood sugar level falls below normal levels, a condition called hypoglycaemia. In severe hypoglycaemia, commonly called insulin shock, the brain is deprived of an essential energy source. The first sign of insulin shock is mild hunger, quickly followed be dizziness, sweats, palpitation, mental confusion and eventual loss of consciousness. Before the condition reaches emergency proportions, most diabetics learn to counteract the symptoms by eating a piece of candy or by drinking a glass of orange juice. In some cases, the only effective measure is an iv injection of glucose.
Drug therapy
Insulin was the first, and remains the best means of treatment for diabetes. It is given by sc injection. This method is necessary since orally-given insulin is destroyed by gastric (ST) secretions. Many diabetics inject insulin only once a day, thus duplicating the normal insulin action of a non-diabetic. Others require 2 or more injections. The usual time for a dose of insulin is before breakfast. The dosage is established initially according to the severity of the condition, but it often has to be reassessed as one or another of the variables in the person's condition changes.
Oral hypoglycaemic agents were developed in the 1950s for controlling milder cases of diabetes that develop in people over 45. They are used to stimulate the release of insulin from the pancreas and foster insulin activity in other ways. None of the oral agents should be used as a substitute, however, for insulin in the ketoacidosis-prone patient since they are not oral forms of insulin.
Choate_C3 (1996) Diabetes mellitus from the perspectives of WM and TCM: Part 3. The biologic half-lives after administration cannot be measured accurately, making the selection of dose and timing of dosing haphazard. Also, use of oral hypoglycaemic drugs has been reported to be associated with increased cardiovascular mortality.
The current use of any of the oral drugs represents to some extent laziness and lack of understanding of the problem at hand with most non-insulin dependent diabetics. Some of the new generation drugs have a specific and beneficial place, if used correctly in patients who are on the appropriate diet and exercise program and are near their optimal weight.
Nutritional therapy
A non-diabetic produces the constantly varying amounts of insulin necessary for obtaining energy from glucose. A diabetic cannot achieve this balance. Apart from the basic need to provide adequate calories and nutrients, the two major groups of diabetics need very different diet strategies. Type I are insulin-dependent non-obese patients (IDDM). Type II are obese patients do not require insulin (NIDDM). In overweight patients, special attention must be given to total caloric consumption; patients who are on insulin therapy must schedule their meals to provide regular caloric intake.
There is no need to disproportionately restrict the intake of carbohydrates in the diet of most diabetic patients. Flexibility in diet design, therefor, helps many patients to adhere to an effective program. Lowering of fat consumption, however, may reduce risk factors of CHD, the main cause of death and debility in the diabetic. 1/3 diabetic patients in clinical surveys has hyperlipidaemia, clearly indicating the need for dietary management. This is reflected in the standard diet and food exchange lists revised in 1976 by the American Diabetes Assoc which restricts the intake of fat to 35% of calories.
In the system of food exchanges the calculation of the proper diet and the selection of foods by the patient are divided into 6 food lists. In each is listed the kind and amount of food with about the same nutritional value in carbohydrate, protein, and fat. The diet exchange method is based on "Exchange Lists for Meal Planning" prepared by and available from the American Diabetes Assoc and the American Diabetic Assoc.
One of the first dietary rules for all diabetics is to avoid all sugar and food containing sugar, such as pastry, candy, and soft drinks. While these refined sugars and other simple carbohydrates like white flour must be carefully watched, most diabetics are encouraged to eat more complex carbohydrates, the same bulky, fibre-rich unprocessed foods that are now recommended for everyone. Vegetables are ideal. For example, a diabetic can eat a large plate of spinach, which contains as much carbohydrate as a tablespoonful of sugar, without suffering any ill effects.
Spinach, asparagus, broccoli, cabbage, string beans, and celery are among the so-called "Food Exchange Group A" vegetables which the American Diabetes Assoc says can be generously included in the diabetic diet. What makes these complex carbohydrates special is their ability to slow down the body's absorption of carbohydrates by helping to delay the emptying of the stomach and thereby smoothing out the absorption of sugars into the blood. Whole grain cereals also have this ability.
Since diabetics are also particularly prone to atherosclerosis with the complicating problems of heart attacks, strokes, and poor circulation to the feet, they must also limit the amount of fat in their diet and to substitute polyunsaturated fats for the saturated type when possible. Fish and poultry are especially recommended instead of fatty cuts of meat. Greasy, fried foods are strongly discouraged.
In diabetics, platelets, the blood elements which are part of the blood clotting mechanism, tend to clump together too quickly. This condition is thought to contribute to vascular complications such as retinal haematoma, coronary thrombosis, and microangiopathy. At least 8 natural substances are known to inhibit abnormal platelet adhesiveness. These include, Vitamins C, E, B6, Linoleic acid, onions, garlic, bromelin, and mackerel- the active ingredient in mackerel being eicosapentaenoic acid. Important tests to measure for platelet aggregation and other conditions which may indicate the progression of atheroma include test for cholesterol, HDL-cholesterol, triglycerides, and a treadmill EKG.
By carefully calculating the proper daily calorie intake for their body weight and activity level, and never exceeding it, overweight diabetics can usually reduce their weight to an optimal level, a level which is 10% less than that recommended by standard height and weight charts.
"The overweight diabetic who successfully brings their weight back to normal usually experiences a dramatic improvement in their condition. Indeed, the symptoms often virtually disappear," says Charles Weller MD, in his book, The New Way To Live With Diabetes (Doubleday, NY rev. 1976). "Weight reduction and control can bring this incurable disease closer to complete remission than any medication.".
Many diabetics eat smaller, more frequent meals, rather that the 2 or 3 big meals most people consume daily. Multiple frequent feedings tend to keep blood cholesterol levels lower, for the diabetic and non-diabetic alike. Since diabetics eat less than most of us, they are advised to make every calorie count.
Generally, a well-balanced diet, rich in vitamins and minerals, is a main factors in the control of diabetes. Some authorities find that the diabetic is unable to convert carotene into vitamin A, while others deny such findings. It is advisable, therefore, for the diabetic to ingest at least the Recommended Dietary Allowance of vitamin A from a non-carotene source, such as fish-liver oil. Diabetics and others on low-fat diets often need supplemental amounts of this fat-soluble nutrient.
A vitamin E supplement (400-1200 IU/d) and a vitamin C supplement (1000-4000 mg/d) is recommended also to help prevent disease of the small-vessels of the extremities. Diabetics, like everyone else, need all the known nutrients, including 12 vitamins and 17 minerals. To be sure of getting the full range of trace elements and other nutrients, diabetics are encouraged to eat the widest possible variety of permitted foods, as well as taking supplements. Certain nutrients (vitamins C, B1, B2, B12, pantothenic acid, protein, and K) along with small frequent meals containing some carbohydrate, can stimulate production of insulin within the body. Supplementary Zn, Cr, and Mn also have been associated with the treatment of diabetes.
Brewer's yeast is another food supplement that is recommended for the diabetic patient. The yeast is a rich source of Cr-containing GTF (glucose tolerance factor), which can potentiate the insulin in our bodies. Both brewer's yeast (9 gm/d) and trivalent Cr (150-1000 ug/d) can significantly improve blood sugar metabolism when taken for several wk to mo. Brewer's yeast and Cr supplementation also lower elevated total cholesterol and total lipids, and significantly raise the levels of HDL-cholesterol- the beneficial or protective fraction of cholesterol. Diabetics who wish to minimize the ill effects of their condition should also eliminate cigarette smoking and alcohol and follow a program of moderate but regular exercise. It is also important to wear shoes which do not cause abrasions of the feet since a small sore that may be a nuisance to most people can lead to gangrene in a diabetic.
Choate_C4 (1996) Diabetes mellitus from the perspectives of WM and TCM: Part 4.
| Vitamin | Amount (when available) |
| Vitamin B complex | |
| Inositol | 2-6 g |
| Vitamin B6 | 500-1000 mg |
| Niacin | up to 100 mg |
| Vitamin B1 | 10 mg |
| Vitamin B2 | 10 mg |
| Vitamin B12 | >25 mcg |
| Vitamin C | 1000-4000 mg |
| Vitamin D | 400 IU |
| Vitamin E | 400-1200 IU |
| Unsaturated FAT | 2 Tbsp |
| Lecithin | 3 Tbsp |
| plus Protein, Panothenic acid, Pangamic acid, Ca, Fe | |
| Cr | 150-200 mg |
| Mg | 500 mg |
| Mn | up to 50 mg |
| K | 300 mg |
| Zn | 100-150 mg |
| Vanadyl Sulphate | 100-150 mg |
| Main points | Functions |
| M-BW12 (Yishu) | Controls pancreatic function |
| BL13 | LU Shu-Back point to drain Heat from Upper Jiao |
| BL20 | SP Shu-Back point to drain Heat from Middle Jiao |
| BL23 | KI Shu-Back point to drain Heat from Lower Jiao |
| ST36 | ST He-Sea, Uniting, Earth and Hour point |
| KI03 | KI Yuan point. |
| Points | Functions |
| LI11 | Drains Fire from LU |
| LI10 | Drains Fire from LU. |
| BL17 | Hui-Meeting point of Xue. Nourishes Jin-Ye. |
| N-BW10 | >(Pirexue) |
| BL21 | ST Shu-Back point to drain Heat from Middle Jiao |
| CV12 | ST Mu-Front point to drain Heat from Middle Jiao |
| CV04 | Strengthens Yuanqi in urinary frequency and KI-Yang-Xu |
| KI07 | Used together to stabilize KI-Qi |
| KI05 | Used together to stabilize KI-Qi. |