Chinese Treatment for Diabetes
Diabetes has been described repeatedly in the ancient Chinese medical literature, and the disease has been treated with Chinese herbs for at least 2,000 years. In the Huang Di Nei Jing (1), the condition known as xiao ke is mentioned, and this is translated today as diabetes or diabetic exhaustion (the literal translation is emaciation-thirst). According to this ancient text, the syndrome arises from consuming too much fatty, sweet, or rich foods; it is said that it typically occurs among wealthy people: "you ask them to refrain from a rich diet, which they may resist." The description fits that of type 2, or insulin-independent diabetes mellitus, the most common form of diabetes that exists today. Two of the traditional formulas most frequently used in modern China and Japan for the treatment of diabetes were described in the Jin Gui Yao Lue (2), about 200 A.D. One is Rehmannia Eight Formula (Ba Wei Di Huang Tang), originally indicated for persons who showed weakness, fatigue, and copious urine excreted soon after drinking water; in some cases, this may have been diabetes as we know it today. The other is Ginseng and Gypsum Combination (Bai Hu Jia Ren Shen Tang), used more in modern Japan than China; it was indicated originally for severe thirst and fatigue and is considered ideal for diabetes of recent onset.
In 752 A.D., the distinguished physician Wang Tao published the famous book Wai Tai Mi Yao, which was a comprehensive guide to medicine (3). In it, he mentioned that diabetes was indicated by sweet urine and he recommended the consumption of pork pancreas as a treatment, implying a conclusion that the pancreas was the organ involved in the disease (he also recommended animal liver for night blindness, sheep's thyroid and seaweed for goiter, and other remedies that seemed to anticipate the results of scientific studies that would be undertaken more than a thousand years later). Further, he suggested that the urine of diabetes patients should be tested daily to determine the progress of the disease and its treatment.
Liu Wansu (ca. 1120-1200 A.D.) propounded the theory that diseases are usually caused by heat in the body, which should be countered by herbs that had a cold nature (4). His theory, in relation to diabetes, has largely been retained to the present, and the initial stage of the disease is treated primarily by herbs that clear heat and nourish yin. One of his published formulas for diabetes, Ophiopogon and Trichosanthes Combination (Mai Men Dong Yin Zi), is comprised almost entirely of herbs that have been shown by modern research to lower blood sugar. Another of his formulas, Siler and Platycodon Formula (Fang Feng Tong Sheng San), is recommended by many Japanese doctors for treatment of obesity and accompanying type 2 diabetic syndrome (5).
By the latter half of the 20th century, there were about 200 standard prescriptions recorded as suitable for treating diabetes (6). The majority of these may be described as combinations selected from about two dozen main anti-diabetic ingredients to be described in this article plus a small number of auxiliary herbs with complementary properties or aimed at treating a specific manifestation of the disease.
In China, diabetes is not as prevalent as elsewhere. The incidence rate is reported to be 0.67% (7), compared to about 2.2% (8) in the U.S. (90% of the U.S. cases are insulin-independent type). This difference may be due to a combination of genetic factors (diabetes runs in families, so has a genetic component), obesity frequency and severity (modern China has far less problem with obesity than the U.S.), and specific dietary components (milk, which is rarely used in China, may be implicated in some instances of insulin-dependent diabetes and nitrosamine-preserved foods may also be sensitizing to this disease (9); herbs used in Oriental food therapy, such as the Chinese yam, bitter melon, and ginseng tea, reduce blood sugar (10)). World-wide estimates of diabetes incidence are on the order of 1.0%, placing China among the group of nations with low incidence and the U.S. in the high incidence category.
The disease etiology-according to traditional ideas-is described this way in modern China (7): "Diabetes mellitus originates from deficiency of yin and is manifested externally as a syndrome of excessive heat. With progress of the disease, deficiency of yin produces dry-heat which in turn damages qi and yin, leading to deficiency of both yin and yang." In light of this explanation, researchers examining 60 diabetes patients, mostly with insulin-independent type diabetes, found that the first stage of disease (with yin deficiency and excess heat) developed over a period of about 3 years, the intermediate stage (with deficiency of qi and yin) developed over a period of about 5 years, and the late stage (with deficiency of qi, yin, and yang) developed over a period of about 8 years. Disorders of blood circulation also progressed over time. Early-onset insulin-dependent diabetes progresses very rapidly to the third stage in most individuals.
Herbs typically selected for the first stage of diabetes include glehnia, adenophora, ophiopogon, raw rehmannia, scrophularia, asparagus root, anemarrhena, dendrobium, trichosanthes root, gypsum, yu-chu, lycium bark, and pueraria. These have the qualities of nourishing the yin and fluids, draining fire, and preventing dry heat from arising. Overall, the herbs have an effect on the lungs, heart, and stomach, and are said to treat the upper burner of the triple burner system. The dominant symptoms they are intended to address are dryness of the mouth and throat which is not alleviated by drinking, and sensation of heat and dryness of the skin. In the second stage of the disease, herbs that tonify the qi are incorporated into the treatment, including ginseng (or codonopsis), astragalus, atractylodes, polygonatum, pseudostellaria, and dioscorea. These herbs treat the middle burner and address the problems of fatigue and digestive disturbance (including voracious appetite). The third stage of the disease is treated by incorporating kidney and liver tonic herbs, such as cinnamon, aconite, epimedium, ho-shou-wu, lycium fruit, alisma, and cornus. At this later stage, which involves the lower burner, most of the herbs used for the first stage of disease are deleted (rehmannia is usually retained, but a mixture of raw and cooked rehmannia replaces simple raw rehmannia) and herbs for enhancing blood circulation are included, such as moutan, salvia, persica, rhubarb, leech, and carthamus. Generalized prescriptions for treating diabetes may include some mix of the herbs for different stages; the formula to be used is selected from many choices according to how closely the therapeutic actions match the requirements of the person being treated.
The alteration of blood patterns that arises as diabetes progresses is of significance when considering treatment of the secondary effects of diabetic syndrome. The deficiency of qi and yin yields blood dryness that leads to stickiness and stagnation, and yang deficiency of late stage diabetes leads to coldness which allows blood stagnation. Some persons may have a constitutional predisposition to blood stasis which is not directly part of the diabetic syndrome, but which may make diabetes-induced symptoms show up earlier and more severely.
Blood-vitalizing herbs apparently have relatively little impact on the underlying diabetes (treatments that do not emphasize this method of therapy are about as successful as those that do for lowering blood sugar). It is found that patients with diabetes tend to have a dark-red or slightly dark-red tongue (the redness corresponds to the yin deficiency; the darkness to the poor circulation) and have increased blood viscosity. Atherosclerosis progresses faster in persons with diabetes. The nail bed circulation in diabetic patients is abnormal, but it shows improvement after treatment of diabetic syndrome and blood stasis with herbs (11). Blood-vitalizing herbs are used to treat hyperlipidemia, retinopathy, and peripheral neuropathy associated with diabetes. Modern doctors in China have added a blood stasis category to the traditional group of three basic diabetic stages or groups (by the three burners). In one study of 20 patients who were categorized as having a blood stasis type of diabetes, a blood-vitalizing herb injection produced marked improvement in 43% of the patients (12). This shows some benefits from this type of therapy, but does not suggest a high level of success.
Among a group of 625 patients showing vascular complications of diabetes (29), it was found that 11% had yin deficiency with fire syndrome (first stage), 76% had deficiency of qi and yin (second stage), and 13% had yin and yang deficiency (third stage). Of the entire group, 53% showed the traditional symptom-sign complex of blood stasis.
EVALUATING HERBS AND FORMULAS
Some initial laboratory animal studies of blood-sugar lowering effects of herbs were conducted in China, Korea, and Japan during the period 1927-1952 (6,13). Rehmannia, atractylodes, scrophularia, polygonatum, phellodendron, coptis, lycium bark, ho-shou-wu, yu-chu, lonicera, ginseng, and alisma were shown to lower blood sugar, sometimes after producing an initial rise in blood sugar; in several cases, the hypoglycemic effect occurred when the herbs were used to treat blood sugar increases induced by epinephrine.
Since the 1960's, a much invigorated program of diabetes research arose. More sophisticated laboratory studies were made possible by the finding that the toxic chemical alloxan selectively destroys the beta cells of the pancreas. Thus, mice, rabbits, or other laboratory animals treated with this compound suffer from a diabetic syndrome quite similar to that of a person who has insulin-dependent diabetes (type I, early onset). Dr. S. Nagayoshi was able to report that Rehmannia Eight Formula reduced blood sugar in alloxan-treated rabbits in a 1960 journal report (6). Comparing the herbal effects in normal laboratory animals with those in alloxan-treated animals provides some indication of the mechanisms by which the herbs affect blood glucose levels. In more detailed investigations, one can examine the impact of the herbs on hyperglycemia induced by other means, such as epinephrine (imitating stress responses).
Further progress along these lines has been made with studies of a genetic strain of mice, first reported in 1979, that gain weight unusually and begin developing a type 2 diabetes after about 10 weeks of growth. These mice were used in a study of the hypoglycemic role of ginseng and its active constituents in the traditional formula Ginseng and Gypsum Combination (24).
Clinical trials have also been conducted, most of them starting in the 1970's. At the 9th Symposium of Oriental Medicine in 1975, Dr.Takahide Kuwaki reported on partial success in treating 15 diabetes patients with traditional herb formulas; nine of the patients treated (duration 2 to 36 months) showed notable improvements (6). In Beijing, a Diabetes Unit was established in 1975 at the Department of Traditional Chinese Medicine at the Capital Hospital; a summary of their recommendations has been published in English (14); Similarly, in Changchun, the Kuancheng Institute of Diabetes was established; researchers there recently published results of a highly successful clinical trial of herbs used for treating diabetic ketonuria, in which 28 of 33 patients showed marked improvements after consuming a complex formula comprised almost entirely of herbs that individually have hypoglycemic actions (15). These Chinese clinics, and other facilities in China and Japan, have provided herbal treatments to thousands of patients with diabetes, and the results have often been monitored and reported.
LABORATORY ANALYSIS
Perhaps the most extensive laboratory investigation of Chinese herbs for diabetes has been carried out by Huang Ray-Ling and his coworkers at the National Research Institute of Chinese Medicine in Taiwan (16). Dr. Huang tested a variety of herb extracts in both alloxan-treated mice and normal mice, in order to compare the impacts of the herbs with or without insulin involvement. To obtain more significant results, blood sugar responses were monitored at different times after administration of herbs, in glucose tolerance tests, and with differing dosages of the herb materials.
Herbs that showed significant hypoglycemic action in both alloxan-treated and untreated mice were atractylodes (cangzhu), cyperus, liriope (a substitute herb for ophiopogon commonly used in Taiwan), phaseolus (mung bean), and clerodendron. Herbs that showed a substantial hypoglycemic effect in alloxan-treated mice but little effect in normal mice include rehmannia, scrophularia, astragalus, coix, moutan, setaria (millet), lycium bark, lycium fruit, benincasa, trichosanthes root, alisma, pine leaves, and asparagus root. Traditional herb formulas that had significant hypoglycemic activity included Rehmannia Six Formula (Liu Wei Di Huang Tang), Rehmannia Eight Formula (Ba Wei Di Huang Tang), and Ginseng and Gypsum Combination (Bai Hu Jia Ren Shen Tang).
The dosages of herbs administered to the mice to obtain the significant hypoglycemic action ranged from 1.25 to 5.0 grams/kg. These dosages are quite high, and it is difficult to translate to human requirements because of varying metabolic factors, but human dosages would also be expected to be at the high end of typical recommendations.
A summary of mainland Chinese laboratory research on hypoglycemic agents, reported in the books Modern Study and Application of Materia Medica (30) and Pharmacology and Applications of Chinese Materia Medica (13) yielded the following listing of herbs (commonly used items are included here; there were also a small number of additional herbs that showed positive effect but are not included in prescriptions mentioned in any of the published clinical trials).
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