3. Traditional Chinese medicine (TCM), etiology and pathogenesis of diabetes

In the view of traditional Chinese medicine, the etiology and pathogenesis of diabetes shares much in common with biomedical perspectives. Both traditions recognize that diabetes can arise from one's inherited constitution, which in biomedical terms is linked to one's DNA and in Chinese medicine is understood as one's prenatal or "preheaven essence." In other words, it is the vital energy and "Qi-information" one inherits from one's parents and ancestors as well as the amount of Qi-energy a person is equipped with before birth which carries with it one's potential for health and longevity. The etiology of diabetes can originate with preheaven kidney essence or kidney yin deficiency and weakness of the five zang organs that predispose a person to further imbalances such as spleen Qi deficiency and dampness [20].

Similar to biomedicine, it is important in TCM for practitioners of acupuncture and oriental medicine to think about the digestive function of the pancreas in the treatment of diabetes mellitus [20]. In the TCM theory, what was translated (or perhaps even mistranslated and perpetuated) long ago as "spleen" is often said to more closely resemble the pancreas [3, 21]. TCM explanations of the function of spleen Qi relate to digestion, namely the transportation and transformation of fluids, whereas the biomedical understanding of the spleen has nothing to do with digestion. The biomedical spleen plays a key role in the body's lymphatic and immune system. The TCM concept of spleen Qi actually more appropriately fits "pancreas Qi" and it is the function of the pancreas that is weakened and leads to diabetes [22]. For the purposes of congruency, the term "spleen Qi" can be taken to mean "pancreas Qi" throughout this chapter.

In biomedical and Chinese medicine perspectives, lifestyle behaviors are also important and can trigger diabetes. From a biomedical standpoint, epigenetics plays a role. Behaviors such as overeating of certain foods, environmental factors, a sedentary lifestyle, or the opposite overtaxing the body with prolonged stress or overexertion, can turn on genes that lead to

T2DM. Chinese medicine perspectives are similar in that "postheaven" choices or lifestyle behaviors can influence the onset and progression of T2DM. Improper diet, overeating of certain foods and overtaxing the body can weaken the Qi-energy and disrupt the balance of the zang (organs). Likewise, a sedentary lifestyle can weaken the Qi because not enough Qi is generated to invest in the strengthening of the body [23].

energy [8]. Insulin lowers the amount of sugar in the bloodstream and as the sugar level drops, the pancreas also decreases insulin secretion [8]. In T2DM, this process is impaired because as sugar builds up in the bloodstream the pancreatic beta cells release more insulin but over time the beta cells cannot manage the high levels of blood sugar and they start to lose

70 Chinese Medical Therapies for Diabetes, Infertility, Silicosis and the Theoretical Basis

Excess sugar in the blood can affect nerve conductivity by impairing the tiny blood vessels that nourish the nerves leading to neuropathy or sensations of tingling, numbness, burning or pain, especially in the extremities. Over time it can lead to the loss of blood flow to the extremities and develop into gangrene [8]. One of the early signs of nerve and blood vessel damage from T2DM in men is erectile dysfunction [8, 9, 20]. The damage to tiny blood vessels can also lead to retinopathy, blurry vision, eye damage and even blindness [8, 9]. Similarly, high blood glucose levels can injure the delicate blood vessels that make up the filtration system of the kidneys which can lead to irreversible damage and end-stage kidney failure that requires

3. Traditional Chinese medicine (TCM), etiology and pathogenesis of

a person to further imbalances such as spleen Qi deficiency and dampness [20].

In the view of traditional Chinese medicine, the etiology and pathogenesis of diabetes shares much in common with biomedical perspectives. Both traditions recognize that diabetes can arise from one's inherited constitution, which in biomedical terms is linked to one's DNA and in Chinese medicine is understood as one's prenatal or "preheaven essence." In other words, it is the vital energy and "Qi-information" one inherits from one's parents and ancestors as well as the amount of Qi-energy a person is equipped with before birth which carries with it one's potential for health and longevity. The etiology of diabetes can originate with preheaven kidney essence or kidney yin deficiency and weakness of the five zang organs that predispose

Similar to biomedicine, it is important in TCM for practitioners of acupuncture and oriental medicine to think about the digestive function of the pancreas in the treatment of diabetes mellitus [20]. In the TCM theory, what was translated (or perhaps even mistranslated and perpetuated) long ago as "spleen" is often said to more closely resemble the pancreas [3, 21]. TCM explanations of the function of spleen Qi relate to digestion, namely the transportation and transformation of fluids, whereas the biomedical understanding of the spleen has nothing to do with digestion. The biomedical spleen plays a key role in the body's lymphatic and immune system. The TCM concept of spleen Qi actually more appropriately fits "pancreas Qi" and it is the function of the pancreas that is weakened and leads to diabetes [22]. For the purposes of congruency, the term "spleen Qi" can be taken to mean "pancreas Qi" throughout this chapter. In biomedical and Chinese medicine perspectives, lifestyle behaviors are also important and can trigger diabetes. From a biomedical standpoint, epigenetics plays a role. Behaviors such as overeating of certain foods, environmental factors, a sedentary lifestyle, or the opposite overtaxing the body with prolonged stress or overexertion, can turn on genes that lead to

their function [8].

diabetes

dialysis or a kidney transplant [8, 9].

In Chinese medicine, moderation is key. Too much or too little of any one thing can disrupt Qi flow and balance, so just as a sedentary lifestyle weakens the body because it is too yin, a lifestyle that is too yang with a high level of activity that exceeds the body's resources can also weaken the body [23]. In particular, overworking and not balancing one's energy with enough rest or proper nutrition can deplete the vital energy. Chinese medicine also speaks of overindulgence in sexual activity which weakens the energy of the kidneys and depletes the essence. Prolonged stress and emotional imbalance are also factors that weaken the energy of the organs and the Qi, blood, yin and yang and create disharmony in the body that over time leads to disease.

Chinese medicine often refers to diabetes as Xiao Ke (消 渴), which is translated as "wastingthirst disorder" and encompasses diabetes mellitus along with other endocrine or metabolic disorders that fit particular patterns with symptoms of a strong appetite and strong thirst (for example, Xiao Ke could refer to other biomedical diseases like hyperthyroidism). Xiao Ke can also refer to stages of diabetes including prediabetes and diabetic complications [20]. In other words, Xiao Ke is a general term which is not the equivalent of diabetes mellitus. Diabetes mellitus is now often referred to using the Chinese modern term Tang Niao Bing (糖尿病) which is literally glucosuria [20].

The diagnosis Xiao Ke Bing, or Xiao Ke Disease, is a group of symptoms related to diabetes that can be further differentiated. The traditional, San Jiao or "three burners" differentiation of Xiao Ke has been popular since the Song Dynasty and is still taught in acupuncture schools as a textbook TCM understanding of diabetes. However, the three burners' differentiation may not be complete, practical, or applicable in clinic now because there are additional symptoms and patterns that should be taken into consideration [20, 24]. Upper (burner) Xiao Ke was traditionally characterized as Xiao Ke with predominant thirst. Middle (burner) Xiao Ke was characterized by excessive appetite and heat and lower (burner) Xiao Ke was characterized by excessive and frequent urination [23]. In modern times, it is important to not give a TCM diagnosis and Xiao Ke differentiation only according to the predominance of excessive thirst, hunger, or urination. It is more appropriate to look closely at the whole body's system, symptoms and patterns and to take into account all the contributing factors including preheaven essence (congenital inheritance), postheaven lifestyle (diet, exercise and stress), as well as one's emotions and environmental stressors.

To provide an overview, the following are some common TCM pattern differentiations associated with T2DM from acupuncture and Chinese herbal medicine treatment perspectives.

The kidney is central to the Chinese medicine understanding of the pathogenesis of T2DM. The kidney stores the jing-essence or one's inherited, original reserves of vital energy. If one has constitutional kidney deficiency, one may already be deficient in yin and may be predisposed to other organ imbalances. This is somewhat similar to saying that one's genes might set them up for epigenetic changes that can be triggered by certain exposures, lifestyle behaviors, or by prolonged stress or emotional imbalances. Overexertion (such as overworking without adequate rest) and overindulgence in sexual activity deplete the kidney yin and jing [25]. A main etiological dynamic in T2DM is kidney yin deficiency at the root which causes dryness heat symptoms as the branch [20, 25]. The relationship between yin deficiency and dryness heat is a circular mechanism because as dryness heat builds, it further consumes the yin fluids [25]. The hyperactive fire resulting from kidney yin deficiency flares upward, resulting in dryness of the lung and heat in the stomach, which combined with kidney yin deficiency, causes diabetes [25].

In addition, chronic kidney yin deficiency can diminish the generation of kidney yang. Combined kidney yin and yang deficiency can in the long run lead to kidney qi failure, making the kidney unable to regulate the exiting of body fluids and manifesting as the need to urinate directly after drinking [26].

In the Chinese medicine theory, the lung is responsible for the descending and distributing of lung Qi and is the upper source of the circulation of water or body fluids [25, 26]. Heat and dryness that consume the yin fluids can injure the lung which then cannot function as well to distribute body fluids and this can present as thirst. Because the lung Qi is responsible for regulating the body's water passages, if lung Qi fails to do this, water and fluid will go directly downward leading to excessive and frequent urination [25, 26].

The liver also plays a central role in the Chinese medicine view of the pathogenesis of T2DM. It is a fairly recent understanding in biomedicine that emotional stress can trigger the onset of T2DM and it is recognized that stress exacerbates high blood glucose levels in people with T2DM [14, 26, 27]. In Chinese medicine theory, the liver is responsible for regulating the smooth flow of Qi throughout the body. Liver Qi stagnation results from stress or excessive emotions and is particularly associated with anger, frustration, irritability, or depression. Constraint and heat from stagnating liver Qi can cause the liver to overact on the middle Jiao which weakens the pancreas Qi and engenders dampness and can also cause too much heat in the stomach, leading to an excessive appetite. Liver Qi stagnation can engender heat in the blood and cause blood stagnation. Blood stagnation impairs fluid distribution and can be accompanied by phlegm stagnation. Heat turns into dryness heat and consumes the yin and can lead to a deficiency of yin in the liver, kidney and stomach [20]. When the yin cannot properly nourish the luo-collaterals, or smaller branches of the body's main meridians, the luocollaterals can be damaged. In addition, spleen Qi deficiency and the accumulation of dampness or phlegm can lead to the stagnation of phlegm and Blood in the collaterals. Damage of the luo-collaterals manifests as diabetic complications such as hypertension, retinopathy, neuropathy, nephropathy and cardiovascular disease [20].

From a medical Qigong perspective the main causes of T2DM are associated with an imbalanced autonomic nervous system, weakened pancreas energy, low kidney energy and excess energy of the liver. This is based on clinical observation with internal Qi diagnostics, a process in which a trained Qigong practitioner uses medical Qigong techniques to perceive and assess a person's internal Qi-energy flow through the organs and associated meridians.

During a randomized controlled pilot study conducted at Bastyr University in 2010, a particularly striking and common pattern found in patients with T2DM was a disharmony of Qi flow between the liver and pancreas [3]. With medical Qigong subtle energy-based observation, it was very clear to the evaluating medical Qigong practitioner in the 2010 study that the biomedical spleen is not a key player in organ patterns associated with T2DM, but the pancreas and its energy and function are a focal point of the disease. According to five element theory, the phenomenon of the liver (wood element) overpowering or overacting on the pancreas (earth element) [3] was the main dynamic. In addition, an underlying factor observed was a weak kidney or water element. These observations are in alignment with TCM theories about the role of the kidney and yin deficiency affecting the energetic function of other organs. Furthermore, the observation that in many cases of T2DM the role of the liver and its effect on the energetic function of the pancreas emphasizes the impact of stress in modern-day society on the liver energy, whether stress comes from inappropriate diet, lifestyle, the environment, or overwork.

This internal Qi-subtle energy-based observation may provide additional perspectives for TCM therapies for treating T2DM [3]. We have found that Qigong has synergistic effects with other modalities of TCM for treating T2DM. Qigong exercises that focus on boosting kidney and pancreas energy and relieving stress from the liver and autonomic nervous system can be particularly beneficial in managing T2DM [3, 27, 22]. In addition, the self-realization that arises through Qigong self-care practice can help people with T2DM become more aware of the underlying stressors and contributing factors in their condition and to make proactive lifestyle changes.
