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Oksana Nachataia. Features of the classification of diabetes in Chinese medicine.

Dear Colleagues! I decided to write a few words about diabetes mellitus in TCM after reading the article, which was published in 2018 and share with you for discussion. «Five Types of Diabetes: Will New Classification Make Management Easier? Jay H. Shubrook, DO; Sumera Ahmed, MD» (https://www.medscape.com/viewarticle/897960 ). This article talks about the practicability of changing the classification of diabetes mellitus (both type 1 and type 2) with more types of diabetes in order to improve clinical practice and make treatment more accurate. The article immediately caused heated discussions in the comments, which clearly indicates the relevance of this topic. After all, the problem of diabetes is a very acute topic, this is not surprising. As you know, the number of people suffering from diabetes is growing from year to year – just look at the statistics according to WHO https://www.who.int/news-room/fact-sheets/detail/diabetes). We see that medicine is now developing at an enormous pace, many researchers say that exponential growth is characteristic of Western science. Indeed, as we can see, almost every month all the new recommendations for people with diabetes are published in terms of lifestyle, diet and physical activity. But these recommendations are still not unambiguous, they are fully suitable for some patients, but for others they do not always bring the expected benefits. Perhaps an integrative approach would be appropriate here, as Chinese medicine is also developing, it has its own classification of diabetes, and this classification of syndromes has undergone changes and has expanded significantly in recent years. As is known, the main difference in approaches is that in Chinese medicine an increase in blood glucose is considered as part of a single set of symptoms, which is a single syndrome. And each such syndrome is a separate pathogenic mechanism of a certain “breaking down” of metabolic processes. And it is well known to the respected reader. The importance of this classification seems to me in that the causes and starting factors for increasing sugar in each case are clearly visible. They can be completely different. According to TCM, for example, for a group of syndromes of “heat” (re zheng) overeating and stagnation of food, hot weather, inflammation in the intestines, excessive alcohol consumption, and so on provokes an increasing of glucose level. For syndromes associated with the stagnation of qi, the trigger factor for hyperglycemia is often stress, anger, disturbed cyclical sleep and wakefulness, and frustration. On the contrary, for patients with syndromes of “cold” and “emptiness” (exhaustion), as you know, danger of overworking, hypothermia, catarrhal diseases, eating cold raw food exchange metabolic indicates worsen. In a nutshell, according to current publications, a total of about 12 syndromes, including all conditions accompanied by hyperglycemia, are currently isolated in the TCM. This classification appeared relatively recently, when specialists in the field of TCM began to apply an integrative approach to the study of the metabolic syndrome in general and type 2 diabetes in particular. Yes, and when the metabolic syndrome was formed itself as a nosological unit in Western medicine. As is known, 10 or 15 years ago diabetes was considered in the TCM as “thirst and exhaustion syndrome” – “Xiao Ke”, divided into three types (upper, middle and lower thirst – according to the pathogenesis mechanism in upper, middle or lower jiao). Type 1 diabetes is more correlated with upper and middle “thirst”, and type 2 diabetes with “lower thirst” syndrome and partly middle one. Currently, this classification has not lost its significance for those syndromes that are described in it. But, moreover, today’s detailed classification of syndromes includes type 2 diabetes, insulin resistance disorders, and changes in carbohydrate metabolism associated with it, allows us to very accurately determine the trigger factors in terms of increasing glucose levels and, accordingly, preventive measures, diet and lifestyle recommendations. And experts widely use this approach. The TCM approach helps in combination with the methods of Western medicine, although there are still questions. Separately, it must be said that in the TCM, hereditary predisposition to diabetes, as is known, is considered as one of the reasons and is called the “weakness of the first palate” – xiang tian bu zu. Therefore, great hopes are placed on the diagnosis of the genome in terms of susceptibility to diabetes, when even moderately powerful trigger factors can play a decisive role. I would like to bring to your attention the classification of diabetes mellitus already familiar to many in the TCM and invite distinguished colleagues to discuss, since nobody has canceled the epidemic nature of this pathology. I deal in detail with the problems of metabolic syndrome, and your additions and comments will be very interesting to me.

Without pretending to be scientific, since all this information is borrowed from modern editions and lectures of colleagues dealing with diabetes in the TCM, and my own practice, I would like to express my thoughts on the importance of starting factors for increasing glucose levels, the causes of illness in each syndrome, to attempt to workout some recommendations. In my opinion, the subjective symptoms of the patient are undeservedly not given importance. I think that this information will be useful in practice. Too quickly some recommendations in classical Western medicine are replaced by others that deny the previous ones, which means that, in my opinion, the problem is far from being solved.

The first line of syndromes. More relevant to conditions of insulin resistance, type 2 diabetes, prediabetes, metabolic syndrome, NAFLD, combined endocrine pathology, including dysfunction of the thyroid gland, adrenal glands with a simultaneous increase in blood glucose and a violation of other indicators, in particular, mainly insulin and glucagon.

It is known that the concept of “metabolic syndrome” includes several conditions that may be present in a patient – obesity in the abdominal area, arterial hypertension, coronary artery disease, NAFLD, atherosclerosis, and diabetes mellitus. And the root of all these disorders, as is known, is mainly insulin resistance. But Chinese medicine, as you know, has its own vision of this problem, when the root of all the above violations is a certain TCM syndrome (or a combination of 2-3 syndromes), and the whole clinical picture is built on it. For example, one of the syndrome of accumulation of phlegm and heat is characterized by the rapid development of atherosclerosis, and obesity, and fatty hepatosis, and hypertension, and diabetes. That is, by acting on the root syndrome, all manifestations of the metabolic syndrome can be affected, but in this particular patient. Therefore, it seems to me that it is so important to pay attention to the patient’s subjective complaints, as well as to his objective examination, in order to identify the TCM syndrome or a combination of two or three syndromes as accurately as possible. Below, considering the syndromes of TCM, it is necessary to imply here diabetes is a part of global disorders in the body.

1.1. Group of stagnation and heat syndromes.

1.1.1. Impaired transport function in the spleen and stomach with stagnation of qi. Pi Wei Yong Zhi. Another name is “spleen is tied up with thoughts.”

Often, this is a variant of a fairly moderate form of metabolic syndrome, when NAFLD may be present at the same time, the patient periodically has a heat syndrome in the stomach and intestines against the backdrop of stagnant food. Often the syndrome of impaired transport function is combined with the following syndrome (stagnation of liver qi), but it can also occur separately. In TCM, the so-called “unproductive thinking” are among the main reasons for the appearance of this state. Currently, they include information overload, blurred boundaries of the working day, an abundance of unsolvable problems, difficulties in adapting to rapidly changing living conditions, intense competition, and the like.

The main symptoms. In the familiar environment, the patient feels tired, depressed, feels the burden of overworking mental work and problems. On vacation, in a state of carelessness, all indicators improve. There is a distension in the abdomen after eating, obesity in the abdomen, a feeling of stopping food, belching, bloating, and anorexia. Tongue pink, large, with thick, white cover. Pulse “hua”. Usually, treatment is based on the recipes “Mu xiang shun qi wan” (“liu mo tang”), “Ban xia hou po tang” (+ huang lian), “Chai hu shu gan san”, with the addition of any choleretic drugs (LI DAN), in particular the means of the western medicine or western herbal medicine. Acupuncture may be used, especially the ba mai jiao hui xue points of the CHONG MAI and YIN WEI MAI channels.

1.1.2. Liver congestion. Gan yu qi zhi.

Just as in the previous syndrome, in this case there are stagnation in the average jiao. In addition to the symptoms of stagnation of food and stagnation of bile, the symptoms of liver stagnation in the understanding of TCM are in the foreground. From the modern point of view, we can say that the main link in pathogenesis is a violation of the vegetative innervation of the organs of the middle Jiao. NAFLD in this case is often present. All indicators of metabolism, as well as the patient’s subjective well-being, deteriorate in response to emotional stress, frustration, anger, lack of sleep.

The main symptoms. Irritability, anger, depressed mood, insomnia, stiffness and discomfort in the sides. The patient often sighs. Obesity in the abdomen with a feeling of bloating. The level of glucose increases moderately, more often in the morning after sleep. In women, premenstrual syndrome is  marked. The appetite is “capricious,” that is, a complete lack of appetite is replaced, on the contrary, by bouts of hunger. Tongue with a thick white bloom. Pulse “xuan”. The treatment is usually based on the following recipes: CHAI HU SHU GAN SAN, JIA WEI XIAO YAO WAN, LI DAN PAI SHI, MU XIAN CHUN QI WAN, BAN XIA HOU PO TANG with the addition of huang lian, xuan fu hua. Acupupture is widely used on the meridians of Shao Yang, Jue Yin, “SHU” points of the back, “MU” points, and others.

1.1.3.Heat in the liver and stomach. Wei chang shi re.

This condition is a variant of the metabolic syndrome, when inflammation prevails in the body.

The main symptoms. The feeling of heaviness and bloating in the stomach. Appetite steadily increased. Obesity in the abdomen and waist. The face is red. Feeling hot. Insomnia. Irritability for no reason. Dry mouth, sometimes a bitter taste. Stools dry, concentrated urine. Heartburn, bad breath, heavy sweating all day, especially after eating. Sweat with foul odor. Pulse “xuan, hua, shu”. The tongue is red with a yellow, greasy bloom. The level of sugar increases with overeating, food stagnation, stress, alcohol consumption.

In the treatment, DA HUANG HUANG LIAN XIE XIN TANG, XIAO CHENG QI TANG, LONG DAN XIE GAN TANG, FANG FENG TONG SHENG TANG with the addition of zhi mu, yin chen hao, yu jin, tian hua fen can be examples of recipes. Acupuncture helps well when working on the Yang Min, Shao Yang, Jue Yin meridians. Emphasis on the “shu” point of the back and the “wu shu” point.

1.1.4. Congestive of phlegm and heat. Tan re hu jie.

Usually this is a detailed picture of the metabolic syndrome with the rapid development of atherosclerosis, arterial hypertension, hepatosis, hepatitis, obesity.

The main symptoms. Obesity, especially in the abdomen. Heartburn, burning in the stomach and esophagus. Feeling of fullness and congestion in the chest, discomfort in the heart area. Snoring while sleeping. Cough after eating with sputum. Palpitations. Sleep is restless. Sensation of stickiness in mouth with desire to rinse mouth. Appetite is slightly elevated, there is often nausea at the same time. Excessive sweating during the day, sweat with an unpleasant odor. Purulent processes are characteristic (boils and others). The patient feels discomfort in a stuffy room. There is the deterioration of mental functions (no clarity). The chair is unformed, several times a day. Tongue large with yellow, greasy cover. Pulse “xuan or hua, shu”.

The treatment is based on prescriptions WEN DAN TANG +  LONG DAN XIE GAN TANG, XIAO XIAN XIONG TANG (huang lian, ban xia, gua lou), FU FANG DAN SHEN, LI DAN-recipes, +shan zha, ze xie, yin chen hao, chai hu, yu jin, jin qian cao.

For more targeted removal of phlegm from the breast and prevention of atherosclerosis, a combination of fragments of classic recipes with the key ingredient gua lou is used. Ingredients: DAN SHEN, SHA REN, CHEN XIANG, SHI CHANG PU, YUAN ZHI, YU JIN, JU YE, GUA LOU, GUI ZHI, ZHI QIAO, SHAN ZHA, SHEN QU, ZHI GAN CAO, XUE JIE. Acupuncture as an additional method is highly appropriate. It is aimed at removing phlegm, removing heat from yang ming, normalizing shao yang, strengthening the spleen and improving the transport function.

1.1.5. Heat in the stomach and colon. Wei chang shi re.

One of the options for metabolic syndrome. Often this is a long-existing “yang ming fu” syndrome with the corresponding symptoms.

The main symptoms. The entire abdomen is enlarged, feeling of fullness in the stomach. The patient feels hot, easily tolerates cold. Offensive gas, stool with a strong odor, a tendency to constipation or diarrhea with sence of burning in the anus. The feeling of “turbidity” and pain in the forehead periodically sweating of the forehead with a feeling of cold due to the fact that the stomach does not lower the turbid. Sweating of palms and feet, excessive sweating after eating or hot drinking. Bleeding gums, thirst, bad breath. The level of glucose increases with the appearance of constipation, while eating hot, sweet, spicy foods. Conversely, with normalization of stool and reduction of inflammation in the gastrointestinal tract, glucose level decreases. The tongue is red with a yellow or slightly brownish cover. Pulse “da mai” or “hua, shu”.

The treatment is usually based on the recipes “DA HUANG HUANG LIAN XIE XIN TANG”, “BAI HU TANG”, “FANG FENG TONG SHENG TANG”, “TIAO WEI CHENG QI TANG”.

1.1.6. Dampness and heat in the large intestine. Da chang shi re.

We can consider this syndrome as a variation of the previous one, when the clinical symptoms appear more from the side of the large intestine. Namely, the patient feels the burning sensation in the anus during stool, fetid stools and gas, the stool is viscous, unformed, several times a day. The belly is big and bulging. Dry mouth. Urine concentrated. Tongue is red, large, with imprints of teeth. At the root of the tongue is yellow, bold bloom. The level of sugar largely depends on the sharpness of inflammation in the large intestine, therefore, the use of smoked, abundant meat, flour and sweet foods, as well as colds can be a starting factor for worsening the condition. In treatment, an example might be a WU MEI WAN JIA JIAN prescription. Recently, as you know, this recipe is widely used for treatment in the large intestine in general, for various reasons. This is the example of variant of this recipe. Ingredients: WU MEI, FU LING, HUANG LIAN, MU XIANG, DANG GUI, BAI ZHU, ZHI SHI, BAI SHAO, BAI JIANG CAO, GE GEN, GAN CAO.

1.2. Syndromes of emptiness (exhaustion).

Here I want to add that in Chinese medicine it is very important to determine what the pathogenic factor is –  the pathogenic excess or depletion of any substances or functional activity of the organism. Usually, in practice, the patient has both manifestations of a pathogenic excess and exhaustion in the same time, but in each case in different proportions. In the treatment it is necessarily to taken into account. Moreover, in modern practice quite often several syndromes are combined with different pathogenesis, since climatic factors and lifestyle factors contribute to their formation. For example, dampness  and heat in the organs of “yang ming” can be combined with exhaustion of the spleen, or the syndrome of false cold against the background of stagnation of the liver (si ni zheng) is combined with the true emptiness of yang and the cold syndromes of “shao yin”. Therefore, the differential diagnosis in TCM is of great importance, since the therapeutic effect directly depends on this.

1.2.1. Spleen depletion in violation of the transport function. Pi xu bu yun.

Under this syndrome, in addition to the violation of carbohydrate metabolism, there may be severe, rapidly developing fatty hepatosis, pancreatic lipomatosis, cysts in parenchymal organs. Often find a critical decrease in the level of vitamin D, perhaps a slight decrease in thyroid function.

The main symptoms. The abdomen is enlarged, but in shape it is in the form of an apron. The contours of the figures also lose their clarity, as if they are “guttering”, “drooping” down. Pale face with light yellowness (wax shade). The spirit is tired, look tired. Powerlessness, weakness, persistent obsessive thoughts, reduced emotional background, fears. Excessive sweating throughout the day, but perspiration is virtually odorless. Heaviness, bloating in the stomach, even with a small meal. Bad appetite. Often there is nausea associated with the consumption of cold, sweet food, as well as raw vegetables and fruits. The stoole is unformed, smearing. Constipation appears after consuming raw and cold foods. Valnerable to colds. In this case, the stomach also does not lower the turbid due to the weak function of the spleen. Therefore, there is the feeling of cold and “turbidity”, pain in the forehead. The condition worsens when eating raw and cold food, when overworked (both mental and physical), hypothermia, lack of sleep. Often there is a feeling of glomus in the stomach and esophagus. The tongue is pale, without tonus. Pulse “chen”, “xuan or hua”, “wu li”, “huan”.

Examples of recipes can be XIANG SHA LIU JUN ZI WAN, WU LING SAN, agents with choleretic action (LI DAN), BAN XIA HOU PO TANG, XUAN FU HUA TANG. Acupuncture may be used, especially the ba mai jiao hui xue points of the CHONG MAI and YIN WEI MAI channels.

2.2.2. Depletion of spleen and kidney yang. Pi Shen Yang Xu.

This syndrome may be present in patients with fairly severe endocrine disorders, in particular, hypothyroidism, adrenal insufficiency. A critical reduction in vitamin D levels is possible. On the other hand, Yang emptiness syndrome is characteristic of people who live long in cold climates and in difficult living conditions, who experience severe overwork without recovery. Plays a role unhealthy food that does not match the climate.

The main symptoms. Discomfort and weakness in the lower back and knees. Aversion to the cold and cold food. Nocturia. The stoole is unformed. Palpation reveals cold abdomen and back. Sweating, sweat is cold. Valnerable to colds. The spirit is tired, weakness and impotence, aggravated by cold. Feeling that the limbs seem to be “swaddled.” All symptoms are aggravated by hypothermia and overwork. This, for example, may be arterial hypertension, increased glucose, pain in the heart of a compressive nature, deterioration of digestion. All these symptoms improve after resting and warming. Pulse is “chen, xi, wu li”. The tongue is pale with a slightly congestive shade, large; the cover is wet.

The treatment often use recipes JIN KUI SHEN QI WAN + huang lian – 1-1,5, LI ZHONG WAN.

The second line of syndromes, the so-called “Three thirst.” It is characterized by more depletion of qi and yin of the body. More related to type 1 diabetes, conditions associated with a lack of insulin in the blood. This may be initially developed diabetes with a lack of insulin or an outcome, later stages of previous syndromes, when the production of insulin and other hormones is depleted.

2.1. Heat in the lungs (and stomach), fluid damage. (FEI WEI ZAO RE). FEI RE JIN SHANG.

Main symptoms. The thirst with desire to drink; dry tongue, lips and skin; emaciation (loss the weight), impotence, sweating at night and under exertion. The tip and edges of the tongue are red. Pulse “hong, shu”. This is often severe type 1 diabetes, occurs in children or adolescents after a cold. An example of a recipe is BAI HU TANG JIAN, SHENG MAI YIN, SHA SHEN MAI MEN DONG TANG, + huang qin, huang lian, jin yin hua as suppliment to treatment with insulin.

2.2. Accumulation of full heat (dry heat) in the stomach. WEI RE ZHI CHENG.

Main symptoms: feeling of hunger, increased appetite, thirst, emaciation. Abundant urine (not always). Frequent occurrence of caries, inflammation in the oral cavity. Emaciation (loss weight), sweating during the day and at night. Dry mouth, fetid odor from mouth. Excessive sweating after eating. Yellow, dry cover on tongue. Pulse “hua, shu, you li”. More often it is diabetes of the first type or later stages of diabetes of the second type. Treatment is usually based on recipes YU NIU JIAN, ZENG YE CHENG QI TANG, BAI HU JIA REN SHEN TANG, SHENG MAI YIN + huang lian, zhi mu, as suppliment to Western medicine.

2.3. Empty yin of the kidneys. Simultaneous depletion of the yin and yang of the kidneys. Shen yin xu. Yin yang liang xu.

Main symptoms: copious amounts of urine, unclear urine, a film may appear on the surface. Face with a sallow shade, dark circles under the eyes. Dry edges of the ears, elbow skin, cracked heels. Weakness, powerlessness. Pain and weakness in the lower back and knees. Dry mouth. Pulse “chen, xi (shu)”. In the treatment of commonly used recipes LIU WEI DI HUANG WAN + SHENG MAI YIN with additions.

+ sheng huang qi, zhi mu with impotence and weakness.

+ sheng di huang, xuan shen, tian hua fen with thirst and dry mouth.

+ gou qi zi, nv zhen zi, han lian cao, di gu pi with sensation of wave-like heat and dizziness.

+ dan shen, sha ren, chi shao, recipe “TIAN MA GOU TENG YIN” for vascular disorders.

When symptoms of simultaneous exhaustion of yin and yang kidneys JIN KUI SHEN QI WAN JIA JIAN with the addition of huang lian 1-1.5 are usually prescribed .

1.4.Deplition of qi and yin. Qi yin liang xu.

This is later stage of any of the above syndromes. Or it may be a later stage of diabetes in the framework of the metabolic syndrome with a high level of inflammation (heat burns fluids and yin).

The main symptoms. Excessive sweating during the day and at night. Emaciation, weakness, impotence, palpitations, insomnia, dry mouth. Pulse xi, xu, shu. The tongue loses its tonus after overwork, after eating. The combination of classical recipes fragments aimed at filling qi and yin, removing heat and restoring fluids can be taken as a basis.

HUANG QI, ZHI MU, SHI GAO, TIAN HUA FEN, CHAI HU, YU JIN, JIN QIAN CAO, HUANG QIN, HUANG LIAN, MAI MEN DONG, BEI SHA SHEN, SHENG DI HUANG, LU GEN, BAI ZHU, FU LING, WU WEI ZI, DANG SHEN, SHAN YAO, DAN SHEN, SHA REN, MU XIANG, JIE GENG, GAN CAO.

There are separately isolated syndromes characteristic of diabetes complications – for example, heat of blood with manifestations of pruritus and food intolerance, stagnation of blood with vascular disorders, and so on. As you can see, the classification of clinical forms of hyperglycemia in the TCM is quite detailed, and in my opinion, it could serve as an additional tool for research from the standpoint of evidence-based medicine.

Thanks for your attention!!!