Diabetes

a) Pathology

The key hormones that control blood glucose levels are insulin and glucagon and the main organs are the pancreas and the liver. As Waugh(2010) explains, insulin, which consists of about 50 amino acids, is synthesised in the beta cells of the pancreatic islets (islets of Langerhans). It is the key body hormone involved in the storage of the absorbed nutrients in the form of glycogen or fat. Its main function is to lower raised blood nutrient levels of glucose, amino acids and fatty acids.  The other important hormone which works in opposition to insulin is glucogen which is created by the alpha cells of the pancreas.

Glucose Regulation – Campbell & Reece(2005).

As can be seen in the above diagram, the two hormones regulate blood glucose concentration keeping it as constant as possible –  ideally at around 90 mg glucose/100 ml blood. When there is a surplus , insulin promotes glycogen synthesis in the liver and facilitates glucose uptake into the cells, thereby lowering the blood sugar level. When there is a deficit, the action of glucagon is to break down glycogen to glucose in the liver and so raise the blood sugar level.

Stephenson(2011) describes how insulin ensures that blood glucose levels never rise excessively which might harm the body and it is also a necessary factor in allowing body cells to use the glucose which is circulating in the bloodstream. Without insulin the cells starve and die.

The causes of type 2 diabetes are multi-factorial explains Scheen(2003) and include  both genetic and environmental elements. He emphasises that obesity plays a  crucial role in the development of the disease. Stumvoll, Goldstein and van Haeften (2005) stress that there is often a genetic connection with other family members affected.

Type 2 diabetes occurs over years as islets fail from insulin overproduction. Insulin levels become inadequate to overcome the peripheral resistance.

a) The  pancreas starts to fail to produce adequate amounts of insulin (Beta cell deficiency)

b) Bodily tissues become less sensitive to insulin which is known as peripheral insulin resistance.

Due to the lack of insulin or its inability to regulate blood glucose, the blood glucose levels may become very high (hyperglycaemia) leading to symptoms such as extreme thirst, tiredness and a need to pass urine frequently as the body tries to get rid of the excess glucose.

Warning features of undiagnosed diabetes (CICM (2010))

  • Type I diabetes: Short history of thirst, weight loss and excessive urination which progresses rapidly in severity.
  • Confusion/coma with dehydration
  • Type II diabetes: Any of the above or:
  • General feeling of being unwell with thirst and increased need to urinate large amounts of urine which develop over the course of weeks to months.
  • Increased tendency to infections such as cystitis, boils and oral thrush (candidiasis).
  • Poor healing of wounds, particularly to the feet and legs.

Diagnosis

In Albert’s case he felt tired, had excessive urination and some problems with his feet. According to Frykberg et al (2006) – Diabetic foot infections are among the most common causes of diabetes-associated hospitalization and the elderly (Albert is 89) are a higher risk group.

As Alberti and Zimmet(1998) explain most cases of type 2 diabetes are diagnosed because of a combination of vague symptoms such as abnormally increased thirst and urine  volume (particularly at night), recurrent infections (psoriasis, thrush), unexplained weight loss and tiredness.

CICM(2010) – Diabetes may be picked up by routine ‘stix’ testing for glycosuria (glucose in urine) in patients at hospital or by a GP.

Guyton and Hall (2006) explain that to confirm whether someone has diabetes they would be given an oral glucose tolerance test. Longmore et al (2010) describe how the patient after fasting overnight, drinks 75 g of glucose in 300 ml of water. Blood glucose is measured before the drink and at regular intervals. If after 2 hours after the glucose load the value is >=7.8 and <= 11 mmol/l, then there is impaired glucose tolerance. Diabetes is diagnosed if glucose is greater than or equal to 11.1 mmol/l and other diabetic symptoms are present. A  further oral glucose tolerance test is required for a patient with no other symptoms.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b) Treatment

The first step in managing type 2 diabetes is to normalize fasting glucose levels and to this end Longmore et al (2010) recommend a biguanide (Metformin) should be immediately prescribed. Biguanides have actions similar to those of insulin, but work independently of the pancreas. Ripsin, Kang & Urban(2009) concur and add that Metformin, which decreases hepatic glucose output and sensitizes peripheral tissues to insulin, has been shown to decrease mortality rates in patients with type 2 diabetes.

Stumvoll, Goldstein and van Haeften(2005)                                                                Other medications prescribed for diabetes, according to Stephenson(2011), include sulfonylureas and nonsulfonylurea secretagogues, alpha glucosidase inhibitors, and thiazolidinediones. Any of these agents can be combined with another.  Once fasting blood glucose approaches near-normal levels, postprandial glucose is addressed by increasing the dose of the current medications or by adding additional agents.

Lifestyle changes

Kumar and Clark(2009)  argue that the key to treating diabetes is to closely monitor and manage blood-glucose levels by lifestyle changes such as stopping smoking, controlling weight, taking regular exercise and adjusting diet, and by medication. Lebovitz (2011) agrees that although lifestyle modification is necessary, it is rarely, by itself, sufficient to achieve target glycemic goals. In the majority of patients, lifestyle modification must be combined with pharmacologic agents.

Stephenson(2011) describes the ideal diet as being 50% complex carbohydrates (potatoes, pasta and rice); minimum sweet foods, zero alcohol, lots of fruit and vegetables. Fats preferably unsaturated should be less than one third of the diet and low fat proteins such as lean meats, fish and pulses also should be less than one third of the diet.

Mahler and Adler (1999) however caution that diet therapy, although important for the prevention as well as the treatment of all stages of type 2 diabetes, continues to remain poorly understood and highly controversial.

Ripsin, Kang & Urban (2009) emphasise the importance of aggressive management of cardiovascular risk factors (i.e. hypertension and high blood cholesterol), with the use of aspirin, statins, and angiotensin-converting enzyme inhibitors.

Long-Term, Chronic Complications

Several secondary complications usually accompany long-standing diabetes mellitus.

1) Cardiovascular disturbances

Waugh(2010) explains how diabetes is a significant risk factor for cardiovascular disorders. Even when the disease is well controlled angiopathies (changes in blood vessels) may still occur. This may lead to stroke,angina and myocardial infarction

2) Kidney problems

According to Waugh(2010), nephropathy where lesions in the small blood vessels and capillaries supplying the kidney lead to renal failure is a common cause of death in those with diabetes. Stephenson(2011) adds that the kidneys can also be damaged by the increased incidence of cystitis and pyelonephritis.

3) Blindness

Waugh(2010)   – Diabetic retinopathy, where there are lesions in the small blood vessels and capillaries supplying the retina of the eye, is the commonest cause of blindness in adults between 30 and 65 years in developed countries. Diabetes also increases the risk of early development of cataracts and other visual disorders. Also progressive damage to the small blood vessels of the retina can  lead to permanent impairment of vision.

4) Neuropathy

Damage to the small blood vessels which supply the nerves can lead to death of the  peripheral nerves which leads to a loss of feeling in lower extremities – the characteristic “glove and stocking” distribution of a polyneuropathy.

Mononeuropathy where single nerves suddenly may die lmay lead to single nerve pain, palsy, weakness of a muscle group in a limb, or double vision.

5) Infection and skin disease

Waugh(2010) explains that diabetic people are highly susceptible to infection and skin damage. Stephenson(2011) agrees and says that peripheral vascular disease leads to poor circulation which impairs the nourishment of the skin. Infections of the skin  increase and wounds are less likely to heal, possibly leading to an ulcer if not treated with adequate care. Also due to peripheral nerve damage and consequent loss of sensation small injuries are more likely, particularly to the feet ie diabetic foot.

Avoidance of Long term complications

Longmore et al (2010) list a variety of checks that need to take place regularly. To avoid retinopathy (retinal damage) there should be regular eye examinations with an annual fundoscopy (ophthalmoscopic examination). This will also check for cataracts and glaucoma, which are more common in diabetic patients.

Nephropathy – Regular screening for microalbuminuria (urinary protein excretion). Angiotensin-converting enzyme (ACE) inhibitors are an effective therapy for diabetic nephropathy.

Foot problems – Feet should be examined regularly for neuropathy, ischaemia, and ulceration

Cardiovascular risk necesessitates regular blood pressure and cholesterol checks. Kumar and Clark (2009) state that blood pressure control is vital and advise using an angiotensin converting enzyme (ACE) inhibitor or angiotensin II receptor (AIIR) antagonist. Most patients will also benefit from a statin and low-dose aspirin.

 

 

 

 

 

c) TCM interpretation of Diabetes

Liu (2009) explains that in Chinese medicine, diabetes is known as Xiao-Ke (emaciation (Xiao) and thirst (Ke)) and, according to the Chinese medicine theories, is commonly classified into three types (upper, middle and lower).

Upper Wasting – Dryness and Heat in the Lung (Lung-Heat Injuring Fluids). The most prominent symptom is polydipsia (drinking a lot).

Middle Wasting – Dryness and Heat in the Stomach (Blazing Stomach-Fire). The most prominent symptom is polyphagia (excessive eating).

Lower Wasting – Kidney Yin & Jing Deficiency/Exhaustion. The most prominent symptom is polyuria (copious urination).

Summarising the above, untreated acute diabetes can be seen as Yin deficiency with accumulation of Heat or Fire.

Flaws, Kuchinski & Casañas (2003) explain that diabetes is a very complex disease and give 12 different treatment patterns, but summarise by agreeing with Liu that the root  pattern  of  diabetes is a qi and yin dual vacuity with dryness and heat.

Albert has symptoms of tiredness, excessive urination and problems with his feet. It is likely that as an 89 year old with such symptoms that he would have poor circulation and suggests Qi Deficiency with Qi and Blood Stagnation and accumulation of Damp or Phlegm. There is also Kidney Yin and Jing Deficiency as shown by the polyuria. General treatment principles would be to Nourish Yin, Tonify Jing and strengthen the Kidney and also Regulate Qi and Blood.

A full treatment plan could only be devised after finding out his CF and doing a full FTD. Albert may also be receiving Western medication which his body is getting used to. In the initial stages I would first do some gentle Tonifying and Nourishing to build strength and help his body adjust until things settled down.

Stephenson(2011) says that anti-diabetic drugs might be interpreted as both Clearing-Heat and Nourishing Yin and may have side effects of hypoglycaemia and weight gain, which might be interpreted as Spleen Qi deficiency with accumulation of Damp. If Albert had been prescribed such drugs, I would in such circumstances Tonify Spleen Qi and Clear Damp.

Comparing Lifestyle advice

Flaws, Kuchinski & Casañas (2003) advise that although the Chinese Medicine practitioner might have different goals for diet and think in terms of Boosting the Qi, Nourishing Yin, Nourishing the Spleen and Stomach etc, generally lifestyle advice would be very similar between the two systems with the goal being to eat a diet that minimises peaks and troughs in blood glucose and which is low in unhealthy lipids. Moderate exercise would be seen by both systems to be beneficial, though a Chinese medicine practitioner would be more likely to suggest Qigong or Tai Chi as gentle forms of exercise. I know from personal experience that such forms of exercise are now becoming well known in the elderly community.

It was useful to do this essay as although perhaps not many people go to an acupuncturist for diabetic treatment, there will be many patients who are diabetic and some who are diabetic, but don’t yet realise.

 

 

 

 

References

Alberti, K. G. M. M., & Zimmet, P. Z. (1998). Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus. Provisional report of a WHO consultation. Diabetic medicine, 15(7), 539-553.

Campbell, N. A., & Reece, J.B. (2005). Biology. 7th ed. San Francisco: Pearson, Benjamin Cummings.

CICM (2010), CMS Disk Stage 5 Conventional Medical Sciences: Course Manual v2.1 Reading: CICM

Flaws, B., Kuchinski, L. M., & Casañas, R. (2003). The Treatment of Diabetes Mellitus with Chinese Medicine. Blue Poppy Enterprises, Inc.

Frykberg RG, Zgonis T, Armstrong DG, Driver VR, Giurini JM, Kravitz SR, et al (2006) Diabetic foot disorders. A clinical practice guideline, Journal of Foot Ankle Surgery. 2006 Sep-Oct;45(5 Suppl):S1-66.

Guyton, A. C., and J. E. Hall. (2006) Textbook of the medical physiology. 11th ed. Philadelphia: Elsevier Saunders

Kumar P and Clark M L (2009) Clinical Medicine (Kumar and Clark’s Clinical Medicine). 7th Edition. London: Elsevier Saunders

Lebovitz, H. E. (2011). Type 2 diabetes mellitus—current therapies and the emergence of surgical options. Nature Reviews Endocrinology, 7(7), 408-419.

Longmore M, Wilkinson I B, Davidson E H, Foulkes A, Mafi A R (2010). Oxford Handbook of Clinical Medicine (Oxford Handbooks). 8th Edition. Oxford: Oxford University Press

Liu, L. (2009). Essentials of Chinese medicine vol 3. Z. Liu (Ed.). London. Springer-Verlag

Mahler, R. J., & Adler, M. L. (1999). Type 2 diabetes mellitus: update on diagnosis, pathophysiology, and treatment. Journal of Clinical Endocrinology & Metabolism, 84(4), 1165-1171.

Ripsin, C. M., Kang, H., & Urban, R. J. (2009). Management of blood glucose in type 2 diabetes mellitus. Am Fam Physician, 79(1), 29-36.

Scheen, A. (2003). Pathophysiology of type 2 diabetes. Acta Clinica Belgica, 58(6).

Stephenson, C  (2011) The Complementary Therapist’s Guide to Conventional Medicine, 1st Edition, Oxford: Churchill Livingstone

Stumvoll, M., Goldstein, B. J., & van Haeften, T. W. (2005). Type 2 diabetes: principles of pathogenesis and therapy. The Lancet, 365(9467), 1333-1346.

Waugh, A.(2010) Ross and Wilson Anatomy and Physiology in Health and Illness, 11th Edition. Oxford. Churchill Livingstone