Asian traditional Medicine in Diabetes Management
Many of our patients have become interested in exploring traditional medicines from Asia, from acupuncture and qi gong to yoga and Chinese herbs. The goals are diverse: to help manage their diabetes, for side effects related to diabetes and medications, or for other unrelated conditions. Increased insurance reimbursement has increased access to these therapies for many, but people often have questions about what these different therapies are, how they work, and which conditions they may be useful for. In this month's Complementary Corner we'd like to offer some simple definitions and demystify the language of traditional Asian medicines. We'll also explore some of the research about how which therapies (especially acupuncture, tai chi, and qi gong) may be useful for people with diabetes.
Thousands of years in development
Within the US, the most well-known systems of medicine emerging from Asian traditions are probably Ayurveda (from the Indian sub-continent) and Traditional Chinese Medicine ("TCM"):
Ayurveda posits that all individuals have a "Prakriti," or basic constitution, which is established at conception. One’s constitution is made up of three different "forces" or "doshas" (vatta, pitta, and kapha)- which must be kept in harmonic balance. Disease will develop if one of these energies is dominant or depleted, but therapies such as diet, herbs, yoga, and massage may help restore balance. Somebody who is kapha-dominant, for instance, would tend to be very heavy, sluggish, and forgetful, while a pitta-dominant may be of medium build with a fiery temper. The herbs and diet prescribed to our kapha friends will be very different than those recommended to pittas.
Traditional Chinese Medicine also believes in a "life-energy" system within the body, typically called ki or qi (pronounced "chee"). From a TCM perspective, there are "meridians" (invisible lines of energy) which run throughout the body and correspond to the various organs of the body. Imbalance in qi or blocks in the meridians are believed to be the cause of disease. Diet, herbs, acupuncture, and exercise can all be employed to help restore balance to qi. Several subsystems within TCM have been developed throughout Asia - both Korea and Japan have reinterpreted TCM, for example.
These systems of thought thousands of years before the growth of modern ("Western") biomedical sciences such as physiology, biochemistry, and pathology; consequently, the language they use to describe states of health and disease doesn’t usually match with what a physician at a hospital might understand. This, in turn, has led many to dismiss these concepts as pseudoscientific mysticism, despite emerging evidence of benefit from several of these therapies.
We’d like to focus the rest of our discussion on a few related therapies from TCM: acupuncture, qi gong, and tai chi. The other components of Asian medicine are important, but we’ve already touched on many of them in other articles (most TCM and Ayurvedic lifestyle programs insist on fresh food and regular motion). Herbs are another exhaustive subject best covered in other articles. (Berberine, just one of thousands of herbs used in TCM, was covered in our April 2012 Edition.)
Harmonious Flow - Nurturing "QI" in the body
Acupuncture involves the placement of ultra-thin needles in very specific locations in the human body. After a comprehensive intake, the acupuncturist instructs the patient to lie quietly on a table, inserts (sterile) needles, and often may leave the room for 15-30 minutes to allow the patient to relax. Lasers and electrical stimulation at the acupoints may also be used in place of needles (these newer techniques often form the basis of the clinical trials noted below). From a TCM perspective, the therapist is clearing "blocked" meridians which may be causing impairment in qi flow.
From a biomedical perspective, several proposed mechanisms exist. Insertion of the needles is almost certainly causing a release of chemicals like endorphins and serotonin, which can act in different ways to lead to pain relief.1 Other studies have found changes in different parts of the brain when receiving acupuncture, with brain locations varying based on the acupoint selected.2Most of these physiologic effects explain how acupuncture can have benefit in subjective sensations like pain, nausea, depression, and fatigue. The relaxation effect (30 minutes in a quiet room) probably also contributes to the therapeutic benefit experienced by patients.
Qi Gong and Tai Chi are related practices, and involve graceful moving meditations. They both purport to strengthen the flow of qi throughout the body by using physical motion, breathing techniques, and visualization. One key difference is that tai chi motions are intended to have a martial component (i.e., they're essentially kung fu or karate attacks and defenses that have been slowed down to a meditative pace.) Practitioners may practice on their own or with larger groups, and there are many books and DVDs that teach these approaches (larger community centers and health clubs will typically have plenty of classes available).
From a biomedical perspective, the benefits are likely to derive from stress reduction and physical exercise. Rather than trying to treat disease, many proponents of tai chi and qi gong believe these systems strengthen and enhance their health.
Acupuncture in diabetes
Acupuncture has very few trials when it comes to directly affecting blood sugar, lipids, and hormones and most of those studies are only available in Chinese. There have also been a few trials finding benefit in weight management in diabetes. After an eight-week placebo-controlled trial of auricular acupuncture (a technique that applies either seeds or magnets to acupuncture spots on the ears), obese adolescents in the active acupuncture group had significant reductions in BMI (about one point, corresponding to 5-10 pounds, depending on height) and some mixed benefits to total cholesterol and LDL.3 A trial using a laser to stimulate acupuncture points also found BMI and weight reduction after 4 weeks of therapy in a non-placebo-controlled trial.4
There is a greater body of research supporting the use of acupuncture in the potential neurological complications of diabetes such as bladder dysfunction, gastroparesis (delayed stomach emptying), and peripheral neuropathy. All of these complications share the same pathology namely, damage to the nerves caused by excessive blood sugar and inflammation.
Over a 15-day period, 45 individuals with diabetic bladder dysfunction were split into an active group (n=30) and a “sham” acupuncture group (n=15).5 On a subjective 0-3 (0= “total control”, 3= “always wet”) scale of urinary incontinence, the active group improved from 2.4 to 1.4, while the sham group deteriorated from 2.2 to 2.3. Several objective measures of incontinence also improved during this time.
Gastroparesis, a delay in the ability of the stomach to release food, can cause significant a variety of uncomfortable symptoms, including nausea, pain, and vomiting. Observations of patients with gastroparesis found effectiveness in 33 of 35 patients (94.2%) treated with acupuncture, while drug management was effective in 18 of 25 patients (72%).6 A more formal study of 19 individuals for 2 weeks (active=10, sham=9) found improvements in several objective and subjective measures of gastroparesis in the active electro-acupuncture group.7
Peripheral neuropathy, the progressive and painful destruction of nerves in the lower extremities, has also been successfully treated with acupuncture. A small pilot study of seven individuals explored the differences in Japanese and Chinese styles of acupuncture, finding each had slightly different benefits after a 10-week trial.8 A 15-day trial comparing standard and sham acupuncture in 42 patients (21 in each group) found benefit in motor and sensory function in the standard group, with no benefit in the sham group.9 Similar results were found in a 65-patient, three-month trial of acupuncture vs. no treatment, with an effectiveness rate of 87.5% for acupuncture and 64% for no treatment.10
Many of the above trials measured blood sugar during the course of the study. None found significant benefit to glycemic control from acupuncture, though this was not the primary endpoint around which these studies were designed. Several studies have also explored acupuncture for generalized anxiety, and found it to be of significant value.11
Qi Gong and Tai Chi in diabetes
In contrast to acupuncture, tai chi and qi gong may be better for glycemic control and other metabolic parameters of diabetes. Remember that both are essentially slow-moving exercises; whether or not one believes in qi, anybody with diabetes is going to get benefit from exercise. Several studies have now been published examining the effects of these therapies in people with diabetes.
Researchers at Bastyr University near Seattle, Washington (including Dr. Bradley) completed a three-arm trial of 32 patients, comparing qi gong, resistance exercise, and a control group. After 12 weeks, they observed a significant reduction in fasting glucose in the qi gong group (and, to a lesser extent, the resistance exercise group), as well as non-significant trends towards improvements in HbA1c and insulin sensitivity.12 A secondary analysis of this trial also found benefits to perceived stress in the qi gong group and depression in the resistance exercise group.13
An Australian study for 41 participants, randomized to either qi gong or usual care for 12 weeks, also showed benefit from qi gong to HbA1c, insulin resistance, weight, and waist circumference.14Further statistical analysis found the improvements to insulin resistance were related to the weight reduction (ie, people’s insulin resistance improved because they lost weight highlighting the importance of weight reduction).
The related technique of tai chi has been found to have significant benefit on lipids, BMI, and markers of oxidative stress, albeit with no significant effects on HbA1c.15 Like its cousin acupuncture, tai chi has some evidence of benefit in diabetic peripheral neuropathy16 and supporting peripheral nerve health.17
The metabolic effects of qi gon and tai chi are probably related to the fact that these are, essentially, physical exercises; however because they also have a stress-reducing affect for many people, the benefits may be related to both increasing energy expenditure and increasing insulin sensitivity- while simultaneously reducing the stress hormones that contribute to insulin resistance. For anybody that appreciates having a relaxed, meditative exercise experience, these may be a favored workout choice!
Choosing a therapy
Acupuncturists are licensed healthcare providers in most US states, and should have professional offices and use "sterile technique." Just as you might with any other healthcare provider, we recommend interviewing the acupuncturist to see if they are a good fit for you. Also, acupuncturists typically offer more than just the "needling" experience, and will typically offer valuable advice about diet and exercise. Finally, many acupuncturists use some amount of herbal medicine. If you're working with a naturopathic or medical physician, and have been prescribed herbs or other medications, make sure that your healthcare team has screened these combinations for potential interactions with your medications. (Note: Occasionally, a TCM or acupuncturist will provide dietary or exercise advice that conflicts with your other doctors. What do you do then? We’d recommend you ask all of them to clarify the rationale for the advice given, and then choose which approach you’d like to try. Remember, putting a time limit, say 3 months, on all experimental (even if only experimental for you) treatments is a good idea. Testing your HbA1c before and after a 3 month trial will give you a good indication whether or not your changed approach is “working”.)
Acupuncture may be better for neurologic complications, while qi gong and tai chi are probably better choices for lowering blood sugar. Both are likely to have beneficial effects on chronic pain, mood and energy levels. For qi gong and tai chi, personal preference also plays a large role. Some people appreciate formal classes, others prefer DVDs or YouTube videos in the home. If you haven’t exercised in a while, make sure your physician clears you for starting a new regimen!
In health- Ryan Bradley, ND, MPH and Bill Walter, ND
Lin JG, Chen WL. Acupuncture analgesia: a review of its mechanisms of actions. Am J Chin Med. 2008;36(4):635-645.
Cheng H, Zhang XT, Yan H, et al. Differential temporal neural responses of pain-related regions by acupuncture at acupoint ST36: a magnetoencephalography study. Chin Med J (Engl). Apr 2011;124(8):1229-1234.
Hsieh CH. The effects of auricular acupressure on weight loss and serum lipid levels in overweight adolescents. Am J Chin Med. 2010;38(4):675-682.
Hu WL, Chang CH, Hung YC. Clinical observations on laser acupuncture in simple obesity therapy. Am J Chin Med. 2010;38(5):861-867.
Tong Y, Jia Q, Sun Y, Hou Z, Wang Y. Acupuncture in the treatment of diabetic bladder dysfunction. J Altern Complement Med. Aug 2009;15(8):905-909.
Wang L. Clinical observation on acupuncture treatment in 35 cases of diabetic gastroparesis. J Tradit Chin Med. Sep 2004;24(3):163-165.
Wang CP, Kao CH, Chen WK, Lo WY, Hsieh CL. A single-blinded, randomized pilot study evaluating effects of electroacupuncture in diabetic patients with symptoms suggestive of gastroparesis. J Altern Complement Med. Sep 2008;14(7):833-839.
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. Jun 2007;25(1-2):11-17.
Tong Y, Guo H, Han B. Fifteen-day acupuncture treatment relieves diabetic peripheral neuropathy. J Acupunct Meridian Stud. Jun 2010;3(2):95-103.
Zhang C, Ma YX, Yan Y. Clinical effects of acupuncture for diabetic peripheral neuropathy. J Tradit Chin Med. Mar 2010;30(1):13-14.
Pilkington K, Kirkwood G, Rampes H, Cummings M, Richardson J. Acupuncture for anxiety and anxiety disorders--a systematic literature review. Acupunct Med. Jun 2007;25(1-2):1-10.
Sun GC, Lovejoy JC, Gillham S, Putiri A, Sasagawa M, Bradley R. Effects of Qigong on glucose control in type 2 diabetes: a randomized controlled pilot study. Diabetes Care. Jan 2010;33(1):e8.
Putiri AL, Lovejoy JC, Gillham S, Sasagawa M, Bradley R, Sun GC. Psychological effects of Yi Ren Medical Qigong and progressive resistance training in adults with type 2 diabetes mellitus: a randomized controlled pilot study. Altern Ther Health Med. Jan-Feb 2012;18(1):30-34.
Liu X, Miller YD, Burton NW, Chang JH, Brown WJ. Qi-gong mind-body therapy and diabetes control. A randomized controlled trial. Am J Prev Med. Aug 2011;41(2):152-158.
Chen SC, Ueng KC, Lee SH, Sun KT, Lee MC. Effect of t'ai chi exercise on biochemical profiles and oxidative stress indicators in obese patients with type 2 diabetes. J Altern Complement Med. Nov 2010;16(11):1153-1159.
Li L, Manor B. Long term Tai Chi exercise improves physical performance among people with peripheral neuropathy. Am J Chin Med. 2010;38(3):449-459.
Hung JW, Liou CW, Wang PW, et al. Effect of 12-week tai chi chuan exercise on peripheral nerve modulation in patients with type 2 diabetes mellitus. J Rehabil Med. Nov 2009;41(11):924-929.