Jillian L. Capodice, LAc examines how acupuncture and Traditional Chinese Medicine can aid Diabetes mellitus.

by  Jillian L. Capodice, LAc

Diabetes mellitus (DM) refers to a group of common metabolic disorders related to hyperglycemia. While there are many different types of DM, DM is increasing in incidence worldwide and predisposes one to numerous other medical conditions including cardiovascular, renal disease, lower extremity amputations and adult blindness.1

The two classes of DM are Type 1 and Type 2 diabetes.  DM Type 1 is characterized by total or near-total insulin deficiency and Type 2 DM are a heterogeneous group of disorders that all have defining features based on:

  • degree of insulin resistance
  • impaired insulin secretion
  • increased production of glucose

The etiology of DM Type2 are numerous and include genetic defects of insulin or beta cell function, exocrine pancreatic diseases, endocrine disorders such as hyperthyroidism and Cushing’s syndrome, drug induced DM, pregnancy induced DM, and increased prevalence of obesity and reduced activity levels worldwide.  In the United States, the Centers for Disease Control (CDC) reported that between 1980-2005, the number of Americans with DM increased from 5.6 to 15.8 million and that people aged 65 years or older accounted for approximately 38% of that total. 2&4 

Number (in Thousands) of Persons with Diagnosed Diabetes, by Age, United States, 1980–2005.3

 

Age Group

Year

0–44

45–64

65–74

75+

Total

1980

951

2430

1409

796

5587

1985

1008

2490

1696

1040

6234

1990

1271

2569

1783

1006

6628

1995

1400

3185

2031

1392

8008

2000

2149

5184

2744

1936

12013

2005

2532

7279

3407

2564

15782

 

Treatment of DM

Long-term
Treatment of DM requires a large multidisciplinary team whose goals are to eliminate symptoms related to hyperglycemia, reduce or eliminate complications of DM and help the patient to achieve a normal lifestyle. One treatment goal that is highly important is education of the patient on DM, nutrition and lifestyle/exercise changes.  However, research on a number of botanicals and other complementary therapies is beginning to demonstrate utility for the management of a variety of DM morbidities and complications. Of the Chinese-based botanicals, research on green tea (Camilla sinensis), coptis-huang bai (Rz coptidis), rehmannia (Rx rehmanniae) and ginseng root (Rx ginseng), are among the many botanical agents being studied.

Ginseng  (Rx ginseng)
Ginseng is a well known herb in the Chinese material medica and there are both TCM principles and pharmacologic evidence that ginseng may be beneficial in the treatment of DM with regard to its immunomodulatory and neuroprotective effects. 

Traditional use
Radix ginseng or the Asian species Panax ginseng is one of the most revered herbs in TCM.  Traditional uses of ginseng (pinyin: ren shen) include:

  • supplementing qi
  • supporting the lungs
  • strengthening the spleen
  • generating fluids and quenching thirst
  • benefiting the heart and calming the spirit

Panax ginseng root         American ginseng root and berry

Ginseng rootginseng root & berry

 

There are many varieties of ren shen and traditionally, its properties vary based on how it is prepared (as with many Chinese herbs).  For example, the material medica states that the variety found in Jinlin province is renowned for its exceptional quality or treating ren shen with sugar is less expensive but adequate for basic yin nourishment.  American ginseng root (Panax quinquefolium (pinyin: xi yang shen)) is not as strong as ren shen according to the Chinese materia medica however its traditional uses include:

  • nourishing the yin
  • nourishing the lungs

Active ingredients
The active ingredients in ginseng include more that 45 different constituents.  The most active include: ginsenosides, polysaccharides, peptides, alcohols, vitamins and minerals. The ginsenosides are thought to be the principle active components and more than 40 have been identified.5 Currently, a number of studies are being done on both the Asian and American ginseng species.  A recent review by Luo et al summarizes a variety of in vitro studies have been done on the potential of ginseng to normalized hyerglycemia and include prevention of weight gain, fasting blood glucose, triglyceride and high free fatty acid levels in a hyperglycemia mouse model 7 and reduction of blood glucose, cholesterol and triglyceride levels in the kidney of diabetic rats.8  A recent study also demonstrated that Korean ginseng aqueous ethanolic extract (0.1–1.0 mg/ml) evoked a stimulation of insulin release in isolated rat pancreatic islet cells.9

In vivo studies
A recent study of American ginseng berry juice demonstrated that fasting blood glucose level concentrations  decreased significantly to 157.8 ± 13.9 mg/dL in obese mice gavaged with ginseng versus controls (P < 0.01, compared to the vehicle group of 223.0 ± 18.0 mg/dL).10 

Another study on Panax ginseng demonstrated that ginsenosides (ginsenoside Rh2) isolated from Panax demonstrated a dose-dependent reduction of plasma glucose in rats receiving a single IV injection of ginsenoside.11  Then following three days of ginsenoside treatment (1 mg/kg per i.v. injection, 3 injections) plasma glucose levels fell to the value significantly lower than the control animals (p<0.05).11

Clinical studies
The earliest clinical trial published in 2001 was a pharmacokinetic study that was designed to test 12 healthy individuals’ response to various (placebo or dosages of American ginseng prior to a 25-g oral glucose challenge (13).  The results demonstrated that glycemia was lower over the last 45 min of the test with doses of 1, 2, or 3 g ginseng versus placebo (P < 0.05).13 The researchers then followed up with a second study in 19 subjects taking an oral Korean ginseng preparation as an adjunct to their usual anti-diabetic therapy (diet and/or medications) over 12 weeks.  These results showed that while there was no significant change in their HbA1c, there was  decreased 75g-OGTT-PG (oral glucose tolerance test ) indices and increased fasting-ISI (homeostasis model assessment [HOMA]) and 75g-OGTT-ISI by 33%, compared with subjects that received the placebo (P<0.05).14   Finally, a small clinical study testing ginseng for glucose intolerance in humans that will look at pharmacokinetics and safety was closed to recruitment earlier this year and a second clinical trial that is scheduled to start enrolling will examine the metabolic and therapeutic effects of American and Korean Red Ginseng in 120 subjects with DM type 2.12

Acupuncture for diabetic neuropathy
There are a number of diabetic neuropathies and a few acupuncture studies that are beginning to look at how acupuncture may provide symptom relief for the DM patient with neuropathy. 

 Types of diabetic neuropathies 15

Generalized neuropathy

  • hyperglycaemic neuropathy
  • symmetric distal polyneuropathy with/without autonomic neuropathy
  • acute painful sensory neuropathy variants

Focal and multifocal neuropathy

  • cranial neuropathies
  • focal limb neuropathies
  • thoracolumbar radiculoneuropathy
  • lumbosacral radiculoplexus neuropathy (Bruns-Garland syndrome)

In general, the most common symptoms reported for leg and foot neuropathy include complaints “of tingling, buzzing or prickling sensations affecting the feet, which may also feel tight or hot or cold. The symptoms are often, but not exclusively, symmetric in distribution. The patient may complain of numbness or “as if my feet are wrapped up in cotton wool.” 15

A recent pilot study in humans tested TCM and Japanese style acupuncture for the treatment of painful diabetic neuropathy. Out of seven patients enrolled, three received Traditional Chinese acupuncture (TCA) while four received Japanese-style acupuncture (JA).  Of six evaluable subjects, JA subjects noted a greater decrease in pain, but the decrease was less durable than the TCA subjects.  The TCA subjects also noted greater sensation improvement in cooling and warming.16  However, since this was a pilot intervention, there were no definitive conclusions.

Lastly, one important thing to note is that foot complications are extremely common among DM patients and acupuncture should not be applied to any ulcerative area and distinct consideration must be made regarding clean needle technique when treating subjects with diabetic neuropathy.

Acupuncture for gastroparesis
Another complication of DM where acupuncture may be useful is increasing gastrointestinal motility/delayed gastric emptying (gastroparesis) and constipation or diarrhea related to motility.  Recently, an in vivo dog study demonstrated that electroacupuncture increased postprandial gastric volume in vagotomized dogs versus normal dogs (p < 0.05) and that EA did not affect gastric compliance or tone but helped to restore impaired gastric accommodation in those dogs that had induced vagotomy versus control dogs. 17

 A second trial by Chang et al demonstrated that there was an increase of serum human pancreatic polypeptide during electroacupuncture (baseline vs. acupuncture 56.96 +/- 27.64 vs. 73.11 +/- 22.37 pmol/l; p < 0.05) and postulated that acupuncture may help with the dysmotility that occurs in the DM patient.18  Finally, a newly funded trial that will begin recruitment later this year, is evalutating whether acupuncture is an effective and safe treatment for diabetic gastroparesis in a randomized, double-blind, placebo/sham-controlled crossover trial.

The outcomes of this trial will be quantitiatve questionnaires including the Gastroparesis Cardinal Symptom Index (GCSI), measurement of gastric emptying using a C13-acetate breath test and asessment of qualtiy of life.12

Conclusions
In conclusion, there is considerable research being done on TCM botanicals and acupuncture for symptom management in the patient with DM.  The outcomes of  these studies will help to inform how herbs, lifestyle interventions and acupucnture are imperative in the comprehensive approach to diabetes care.

References

1.  Harrison’s Principles of Internal Medicine, Chapter 338.

2.  The CDC website: http://www.cdc.gov/diabetes/statistics/prev/national/figpersons.htm.  Accessed on November 15, 2008

3.  CDC Diabetes Data and Trends: http://apps.nccd.cdc.gov/DDTSTRS/default.aspx.  Accessed on November 17, 2008.

4.  The National Diabetes Information Clearinghouse:  http://diabetes.niddk.nih.gov/index.htm Accessed November 17, 2008.

5.  Xiang YZ, Shang HC, Gao XM, Zhang BL. A comparison of the ancient use of ginseng in traditional Chinese medicine with modern pharmacological experiments and clinical trials. Phytother Res. 2008 Jul;22(7):851-8.

6.  Luo JZ, Luo L.Ginseng on Hyperglycemia: Effects and Mechanisms. Evid Based Complement Alternat Med. 2008 Jan 3. [Epub ahead of print]

7.  Liu TP, Liu IM, Cheng JT. Improvement of insulin resistance by panax ginseng in fructose-rich chow-fed rats. Horm Metab Res ( 2005;) 37:: 146–51

8. Cho WC, Chung WS, Lee SK, Leung AW, Cheng CH, Yue KK. Ginsenoside Re of Panax ginseng possesses significant antioxidant and antihyperlipidemic efficacies in streptozotocin-induced diabetic rats. Eur J Pharmacol ( 2006;) 550:: 173–9.

9.  Kim K, Kim HY.Korean red ginseng stimulates insulin release from isolated rat pancreatic islets. J Ethnopharmacol. 2008 Nov 20;120(2):190-5. Epub 2008 Aug 15.

10.  Xie JT, Wang CZ, Ni M, Wu JA, Mehendale SR, Aung HH, Foo A, Yuan CS.American ginseng berry juice intake reduces blood glucose and body weight in ob/ob mice.J Food Sci. 2007 Oct;72(8):S590-4.

11.  Lee WK, Kao ST, Liu IM, Cheng JT.Ginsenoside Rh2 is one of the active principles of Panax ginseng root to improve insulin sensitivity in fructose-rich chow-fed rats. Horm Metab Res. 2007 May;39(5):347-54.

12.  Clinical trials.gov accessed November 17, 2008

13. Vuksan V, Sievenpiper JL, Wong J, Xu Z, Beljan-Zdravkovic U, Arnason JT, Assinewe V, Stavro MP, Jenkins AL, Leiter LA, Francis T.American ginseng (Panax quinquefolius L.) attenuates postprandial glycemia in a time-dependent but not dose-dependent manner in healthy individuals. Am J Clin Nutr. 2001Apr;73(4):753-8.

14. Vuksan V, Sung MK, Sievenpiper JL, Stavro PM, Jenkins AL, Di Buono M, Lee KS, Leiter LA, Nam KY, Arnason JT, Choi M, Naeem A.Korean red ginseng (Panax ginseng) improves glucose and insulin regulation in well-controlled, type 2 diabetes: results of a randomized, double-blind, placebo-controlled study of efficacy and safety. Nutr Metab Cardiovasc Dis. 2008 Jan;18(1):46-56. Epub 2006 Jul 24.

15.  Llewelyn JG.The diabetic neuropathies: types, diagnosis and management. J Neurol Neurosurg Psychiatry. 2003 Jun;74 Suppl 2:ii15-ii19. 

16. Ahn AC, Bennani T, Freeman R, Hamdy O, Kaptchuk TJ. Two styles of acupuncture for treating painful diabetic neuropathy–a pilot randomised control trial. Acupunct Med. 2007 Jun;25(1-2):11-7.

17. Ouyang H, Xing J, Chen J. Electroacupuncture restores impaired gastric accommodation in vagotomized dogs. Dig Dis Sci. 2004 Sep;49(9):1418-24.

18. Chang CS, Ko CW, Wu CY, Chen GH. Effect of electrical stimulation on acupuncture points in diabetic patients with gastric dysrhythmia: a pilot study. Digestion. 2001;64(3):184-90.


Additional articles by this author: