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TREATMENT OF DIABETES WITH CHINESE HERBS

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

HISTORICAL BACKGROUND

Diabetes has been described repeatedly in the ancient Chinese medical literature, and the disease has been treated with Chinese herbs for at least 2,000 years. In the Huang Di Nei Jing (1), the condition known as xiao ke is mentioned, and this is translated today as diabetes or diabetic exhaustion (the literal translation is emaciation-thirst). According to this ancient text, the syndrome arises from consuming too much fatty, sweet, or rich foods; it is said that it typically occurs among wealthy people: "you ask them to refrain from a rich diet, which they may resist." The description fits that of type 2, or insulin-independent diabetes mellitus, the most common form of diabetes that exists today. Two of the traditional formulas most frequently used in modern China and Japan for the treatment of diabetes were described in the Jin Gui Yao Lue (2), about 200 A.D. One is Rehmannia Eight Formula (Ba Wei Di Huang Tang), originally indicated for persons who showed weakness, fatigue, and copious urine excreted soon after drinking water; in some cases, this may have been diabetes as we know it today. The other is Ginseng and Gypsum Combination (Bai Hu Jia Ren Shen Tang), used more in modern Japan than China; it was indicated originally for severe thirst and fatigue and is considered ideal for diabetes of recent onset.

In 752 A.D., the distinguished physician Wang Tao published the famous book Wai Tai Mi Yao, which was a comprehensive guide to medicine (3). In it, he mentioned that diabetes was indicated by sweet urine and he recommended the consumption of pork pancreas as a treatment, implying a conclusion that the pancreas was the organ involved in the disease (he also recommended animal liver for night blindness, sheep's thyroid and seaweed for goiter, and other remedies that seemed to anticipate the results of scientific studies that would be undertaken more than a thousand years later). Further, he suggested that the urine of diabetes patients should be tested daily to determine the progress of the disease and its treatment.

Liu Wansu (ca. 1120-1200 A.D.) propounded the theory that diseases are usually caused by heat in the body, which should be countered by herbs that had a cold nature (4). His theory, in relation to diabetes, has largely been retained to the present, and the initial stage of the disease is treated primarily by herbs that clear heat and nourish yin. One of his published formulas for diabetes, Ophiopogon and Trichosanthes Combination (Mai Men Dong Yin Zi), is comprised almost entirely of herbs that have been shown by modern research to lower blood sugar. Another of his formulas, Siler and Platycodon Formula (Fang Feng Tong Sheng San), is recommended by many Japanese doctors for treatment of obesity and accompanying type 2 diabetic syndrome (5).

By the latter half of the 20th century, there were about 200 standard prescriptions recorded as suitable for treating diabetes (6). The majority of these may be described as combinations selected from about two dozen main anti-diabetic ingredients to be described in this article plus a small number of auxiliary herbs with complementary properties or aimed at treating a specific manifestation of the disease.

In China, diabetes is not as prevalent as elsewhere. The incidence rate is reported to be 0.67% (7), compared to about 2.2% (8) in the U.S. (90% of the U.S. cases are insulin-independent type). This difference may be due to a combination of genetic factors (diabetes runs in families, so has a genetic component), obesity frequency and severity (modern China has far less problem with obesity than the U.S.), and specific dietary components (milk, which is rarely used in China, may be implicated in some instances of insulin-dependent diabetes and nitrosamine-preserved foods may also be sensitizing to this disease (9); herbs used in Oriental food therapy, such as the Chinese yam, bitter melon, and ginseng tea, reduce blood sugar (10)). World-wide estimates of diabetes incidence are on the order of 1.0%, placing China among the group of nations with low incidence and the U.S. in the high incidence category.

The disease etiology-according to traditional ideas-is described this way in modern China (7): "Diabetes mellitus originates from deficiency of yin and is manifested externally as a syndrome of excessive heat. With progress of the disease, deficiency of yin produces dry-heat which in turn damages qi and yin, leading to deficiency of both yin and yang." In light of this explanation, researchers examining 60 diabetes patients, mostly with insulin-independent type diabetes, found that the first stage of disease (with yin deficiency and excess heat) developed over a period of about 3 years, the intermediate stage (with deficiency of qi and yin) developed over a period of about 5 years, and the late stage (with deficiency of qi, yin, and yang) developed over a period of about 8 years. Disorders of blood circulation also progressed over time. Early-onset insulin-dependent diabetes progresses very rapidly to the third stage in most individuals.

Herbs typically selected for the first stage of diabetes include glehnia, adenophora, ophiopogon, raw rehmannia, scrophularia, asparagus root, anemarrhena, dendrobium, trichosanthes root, gypsum, yu-chu, lycium bark, and pueraria. These have the qualities of nourishing the yin and fluids, draining fire, and preventing dry heat from arising. Overall, the herbs have an effect on the lungs, heart, and stomach, and are said to treat the upper burner of the triple burner system. The dominant symptoms they are intended to address are dryness of the mouth and throat which is not alleviated by drinking, and sensation of heat and dryness of the skin. In the second stage of the disease, herbs that tonify the qi are incorporated into the treatment, including ginseng (or codonopsis), astragalus, atractylodes, polygonatum, pseudostellaria, and dioscorea. These herbs treat the middle burner and address the problems of fatigue and digestive disturbance (including voracious appetite). The third stage of the disease is treated by incorporating kidney and liver tonic herbs, such as cinnamon, aconite, epimedium, ho-shou-wu, lycium fruit, alisma, and cornus. At this later stage, which involves the lower burner, most of the herbs used for the first stage of disease are deleted (rehmannia is usually retained, but a mixture of raw and cooked rehmannia replaces simple raw rehmannia) and herbs for enhancing blood circulation are included, such as moutan, salvia, persica, rhubarb, leech, and carthamus. Generalized prescriptions for treating diabetes may include some mix of the herbs for different stages; the formula to be used is selected from many choices according to how closely the therapeutic actions match the requirements of the person being treated.

The alteration of blood patterns that arises as diabetes progresses is of significance when considering treatment of the secondary effects of diabetic syndrome. The deficiency of qi and yin yields blood dryness that leads to stickiness and stagnation, and yang deficiency of late stage diabetes leads to coldness which allows blood stagnation. Some persons may have a constitutional predisposition to blood stasis which is not directly part of the diabetic syndrome, but which may make diabetes-induced symptoms show up earlier and more severely.

Blood-vitalizing herbs apparently have relatively little impact on the underlying diabetes (treatments that do not emphasize this method of therapy are about as successful as those that do for lowering blood sugar). It is found that patients with diabetes tend to have a dark-red or slightly dark-red tongue (the redness corresponds to the yin deficiency; the darkness to the poor circulation) and have increased blood viscosity. Atherosclerosis progresses faster in persons with diabetes. The nail bed circulation in diabetic patients is abnormal, but it shows improvement after treatment of diabetic syndrome and blood stasis with herbs (11). Blood-vitalizing herbs are used to treat hyperlipidemia, retinopathy, and peripheral neuropathy associated with diabetes. Modern doctors in China have added a blood stasis category to the traditional group of three basic diabetic stages or groups (by the three burners). In one study of 20 patients who were categorized as having a blood stasis type of diabetes, a blood-vitalizing herb injection produced marked improvement in 43% of the patients (12). This shows some benefits from this type of therapy, but does not suggest a high level of success.

Among a group of 625 patients showing vascular complications of diabetes (29), it was found that 11% had yin deficiency with fire syndrome (first stage), 76% had deficiency of qi and yin (second stage), and 13% had yin and yang deficiency (third stage). Of the entire group, 53% showed the traditional symptom-sign complex of blood stasis.

EVALUATING HERBS AND FORMULAS

Some initial laboratory animal studies of blood-sugar lowering effects of herbs were conducted in China, Korea, and Japan during the period 1927-1952 (6,13). Rehmannia, atractylodes, scrophularia, polygonatum, phellodendron, coptis, lycium bark, ho-shou-wu, yu-chu, lonicera, ginseng, and alisma were shown to lower blood sugar, sometimes after producing an initial rise in blood sugar; in several cases, the hypoglycemic effect occurred when the herbs were used to treat blood sugar increases induced by epinephrine.

Since the 1960's, a much invigorated program of diabetes research arose. More sophisticated laboratory studies were made possible by the finding that the toxic chemical alloxan selectively destroys the beta cells of the pancreas. Thus, mice, rabbits, or other laboratory animals treated with this compound suffer from a diabetic syndrome quite similar to that of a person who has insulin-dependent diabetes (type I, early onset). Dr. S. Nagayoshi was able to report that Rehmannia Eight Formula reduced blood sugar in alloxan-treated rabbits in a 1960 journal report (6). Comparing the herbal effects in normal laboratory animals with those in alloxan-treated animals provides some indication of the mechanisms by which the herbs affect blood glucose levels. In more detailed investigations, one can examine the impact of the herbs on hyperglycemia induced by other means, such as epinephrine (imitating stress responses).

Further progress along these lines has been made with studies of a genetic strain of mice, first reported in 1979, that gain weight unusually and begin developing a type 2 diabetes after about 10 weeks of growth. These mice were used in a study of the hypoglycemic role of ginseng and its active constituents in the traditional formula Ginseng and Gypsum Combination (24).

Clinical trials have also been conducted, most of them starting in the 1970's. At the 9th Symposium of Oriental Medicine in 1975, Dr.Takahide Kuwaki reported on partial success in treating 15 diabetes patients with traditional herb formulas; nine of the patients treated (duration 2 to 36 months) showed notable improvements (6). In Beijing, a Diabetes Unit was established in 1975 at the Department of Traditional Chinese Medicine at the Capital Hospital; a summary of their recommendations has been published in English (14); Similarly, in Changchun, the Kuancheng Institute of Diabetes was established; researchers there recently published results of a highly successful clinical trial of herbs used for treating diabetic ketonuria, in which 28 of 33 patients showed marked improvements after consuming a complex formula comprised almost entirely of herbs that individually have hypoglycemic actions (15). These Chinese clinics, and other facilities in China and Japan, have provided herbal treatments to thousands of patients with diabetes, and the results have often been monitored and reported.

LABORATORY ANALYSIS

Perhaps the most extensive laboratory investigation of Chinese herbs for diabetes has been carried out by Huang Ray-Ling and his coworkers at the National Research Institute of Chinese Medicine in Taiwan (16). Dr. Huang tested a variety of herb extracts in both alloxan-treated mice and normal mice, in order to compare the impacts of the herbs with or without insulin involvement. To obtain more significant results, blood sugar responses were monitored at different times after administration of herbs, in glucose tolerance tests, and with differing dosages of the herb materials.

Herbs that showed significant hypoglycemic action in both alloxan-treated and untreated mice were atractylodes (cangzhu), cyperus, liriope (a substitute herb for ophiopogon commonly used in Taiwan), phaseolus (mung bean), and clerodendron. Herbs that showed a substantial hypoglycemic effect in alloxan-treated mice but little effect in normal mice include rehmannia, scrophularia, astragalus, coix, moutan, setaria (millet), lycium bark, lycium fruit, benincasa, trichosanthes root, alisma, pine leaves, and asparagus root. Traditional herb formulas that had significant hypoglycemic activity included Rehmannia Six Formula (Liu Wei Di Huang Tang), Rehmannia Eight Formula (Ba Wei Di Huang Tang), and Ginseng and Gypsum Combination (Bai Hu Jia Ren Shen Tang).

The dosages of herbs administered to the mice to obtain the significant hypoglycemic action ranged from 1.25 to 5.0 grams/kg. These dosages are quite high, and it is difficult to translate to human requirements because of varying metabolic factors, but human dosages would also be expected to be at the high end of typical recommendations.

A summary of mainland Chinese laboratory research on hypoglycemic agents, reported in the books Modern Study and Application of Materia Medica (30) and Pharmacology and Applications of Chinese Materia Medica (13) yielded the following listing of herbs (commonly used items are included here; there were also a small number of additional herbs that showed positive effect but are not included in prescriptions mentioned in any of the published clinical trials).

CLINICAL APPLICATIONS

A sampling of clinical recommendations and evaluative trials for the treatment of diabetes is presented in the book Modern Clinic Necessities for Traditional Chinese Medicine (17). The formulas that had been shown to have hypoglycemic effects in the animal studies, Rehmannia Six Formula and Ginseng and Gypsum Combination, were recommended to treat those who have normal insulin secretion but suffer from diabetes (this would be type 2, or insulin-independent diabetes). These formulas are for the common qi and yin deficiency syndrome. A traditional variation of Rehmannia Six Formula may also be appropriate, made by adding anemarrhena and phellodendron.

Reducing Sugar Tablet A (Jiang Tang Jia Pian), comprised of astragalus, polygonatum, trichosanthes root, pseudostellaria, and rehmannia, was recommended for those with low levels of insulin, but who are still capable of producing insulin. The herbs were administered as extracts in tablet form, with 2.3 grams raw material per tablet, 6 tablets each time, three times daily, for a total dose of over 40 grams per day (raw materials equivalent). The effects were said to be enhancing sugar tolerance and elevating the level of serum insulin. In the treatment of 405 cases of diabetes with this preparation at the Guanganmen Hospital, 76.5% of the patients had improved sugar tolerance. Among those patients who most closely fit the therapeutic pattern of the herbs-those with qi and yin deficiency-the effective rate was slightly higher, 81%.

Rehmannia Eight Formula was recommended for those patients who produced little or no insulin. This is for patients with advanced disease, representing a deficiency of yin and yang (the cinnamon bark and aconite added to Rehmannia Six Formula to produce Rehmannia Eight Formula are said to restore yang). In laboratory animal studies, use of this formula resulted in reduction of water demand (thirst), blood sugar, and sugar spill into the urine. As a result of positive reports resulting from use of this formula for diabetes in Japan, the current author recommended it for those with early-onset diabetes beginning in 1981, using mainly the patent medicine from China, variously called "Sexoton Pills" or "Golden Book Tea" which is the Rehmannia Eight Formula (Ba Wei Di Huang Wan). When consumed in the amount of 12 pills each time, three times daily, it could help reduce the fluctuations in blood sugar that were experienced by insulin-dependent patients who had difficulties gaining control of blood sugar levels. As a result, there was a slight reduction in total insulin usage, but the main benefit was more reliable effects of insulin.

Jade Spring Pill (Yu Quan Wan), a patent formula from China, is recommended for diabetes treatment in the dosage of 50 grams per day (the original form was large honey pills of about 6 grams each), for at least one month. In laboratory animal studies, this formula was shown to increase glycogen in liver cells (the single herb rehmannia also has this effect in laboratory animals). When the current author visited the Sichuan Province United Pharmaceutical Manufactory, a new product was presented: the second generation of "Yuechung Pills" (Jade Spring Pills), comprised of pueraria, trichosanthes root, rehmannia, licorice, schizandra, and other herbs not mentioned on the label. These pills are indicated in the package labeling for the "ill function of the islets of Langerhans." The relatively small pills are packed into small bottles with a total of 6 grams each, and 20 bottles are packed in one box, accompanied by instructions to take one bottle each time, four times daily (the box is a five day supply at 24 grams/day). Compared to the first generation, it is said on the package insert, the new product had been clinically proved to have an improved rate of cure and that the dose had been reduced. Jade Spring Pill is useful for the early stage of diabetes, when yin deficiency and dryness dominate. In a recent clinical evaluation of a Chinese herb formula for diabetes, Jade Spring Pills, used for the control group, was reported to be effective in reducing blood sugar for 79% of cases treated (33).

Several clinical trials have been reported in Chinese medical journals with brief English summaries appearing in Abstracts of Chinese Medicine (a Hong Kong publication). A representative report is one that originally appeared in the Journal of the Zhejiang Traditional Chinese Medical College in 1989 (18). Patients were treated with a decoction containing astragalus, codonopsis, rehmannia, gypsum, salvia, persica, carthamus, atractylodes (cangzhu), anemarrhena, and tang-kuei. This combination of qi and yin tonics plus blood-vitalizing herbs is appropriate to treating patients with a middle stage disease showing some secondary symptoms. Modifications of the formula would also be made for the specific symptoms. The patients showed a variety of secondary manifestations of the disease, including nephropathy, peripheral neuropathy, dermatological disorders, retinitis, and liver cirrhosis. Among 19 non-insulin dependent cases treated, fasting blood glucose levels decreased from the pretreatment range of 160-300 mg% to 80-110 mg%. One patient with insulin dependent diabetes showed a decline in fasting blood sugar from 500 mg% before treatment to readings of 110-200 mg% after treatment. Generally, it was found that blood glucose decreased after 1-2 weeks of treatment and became steady after one month, and the blood glucose changes were followed by symptomatic improvements.

DOSAGE AND FORM OF ADMINISTRATION

The dosage of herbs applied to treatment of diabetes is often quite high. As revealed by the experience with Reducing Sugar Tablet A and Jade Spring Pills, a formula that is considered highly effective must be taken in dosages of about 12-24 grams per day even when presented as a highly condensed extract (made from about 40-80 grams of crude herbs) in convenient form. This apparent requirement is reflected in several books that recommend herbs in decoction form.

In the book Clinical Experiences (19), a number of different decoctions are suggested. The dosages of the formulas, range from that of an "experiential prescription" containing three herbs (astragalus, rehmannia, and dioscorea, 30 grams each in decoction) at a total dose of 90 grams per day, to a dozen herbs in each of three formulas for yin deficiency syndrome (each prescription contains rehmannia, ophiopogon, and scrophularia) according to the affected "burner," with about 120-150 grams for one day. There is also presented in this book a modified Rehmannia Eight Formula for advanced cases showing yang deficiency, with about 170 gram/day dosage. Regarding efficacy, it is stated that the early onset type of diabetes responds poorly, but the insulin-independent type with slow onset responds favorably.

In the book 100 Famous and Effective Prescriptions of Ancient and Modern Times (20), the Decoction for Diabetes (Yi Tang Tang) is mentioned. It contains rehmannia, trichosanthes root, dioscorea, gypsum, ophiopogon, dendrobium, and seven other herbs. Taken as a decoction, the standard formula is made with 226 grams of herbs for a daily dose. This formula is usually prescribed with additions to address specific symptoms, so that the total daily dosage often reaches 250 grams. In a study with 215 diabetic patients, it was reported that 62 cases were relieved of thirst, overeating, polyuria, and sugar in the urine; the fasting blood glucose declined to below 130 mg%. Additionally, 88 others had some degree of improvement (total effective rate: 70%).

In the book Integrating Chinese and Western Medicine (21), four herb formulas are described following a discussion of Western therapies: one each to treat the three burners and one to treat stagnation of blood. Each of the formulas, a two day supply of herbs, is made with over 250 grams of herb materials (thus, over 125 grams/day). All four formulas contain twelve to thirteen herbs, and they all include pueraria, rehmannia, and salvia. Nothing is said directly about the degree of effectiveness of the formulas, but the text ends with the comment that certain pills "are also very effective," citing Rehmannia Six Formula, Jade Spring Pills, and Diabetes Pills.

In A Clinical Guide to Chinese Herbs and Formulas (22), three formulas for diabetes are presented (according to the burner that is affected). The formulas are comprised of typical hypoglycemic herbs, and the dosage is usually 10-15 grams of each major ingredient, with 6-7 major ingredients, and a total dosage of about 100 grams per day. The formulas can be modified for specific symptoms, which might add about 10 to 30 grams of herbs additionally.

The large amount of raw materials apparently needed for treating diabetes may be a reflection of the need to consume several hundred milligrams of mixed non-toxic active components derived from herbs to attain substantial physiological improvements within a typical treatment period of three months or less. It is expected that most of the anti-diabetic active constituents are present at a level of approximately 2% (or less) of the dried herb material. Decoctions that have 90-150 grams of materials (or more), might yield only about 2 grams of hypoglycemic constituents.

Condensing the active components will yield dried materials that must be taken at a level that is often still regarded as inconvenient by many. For example, dried decoctions (manufactured mainly in Taiwan and Japan) of mixed herbs typically yield a product which is not more than about a 4.5-1.0 concentration factor (450 grams of raw materials yields 100 grams of finished product). Such materials are available in the West and often packaged in units of 100 grams. To obtain the equivalent of a minimal dosage of 90 grams of crude herbs in decoction, one would consume about 20 grams of the dried extracts (a one day dose), and a bottle of herbs would be a 5 day supply. This is similar to the situation with the second generation Jade Spring Pills described above.

Attempts have been made to isolate active constituents, as one way of making treatment more convenient, but one then loses several of the purported advantages of whole herbs and formulas. One item of current interest is the alkaloid berberine, which has many therapeutic uses, including treatment of hyperglycemia. Rats treated with alloxan and with berberine were less likely to show blood glucose rise and pathological change in the beta cells. Insulin-independent diabetes patients treated with 300-500 mg of berberine daily for one to three months (along with dietary control), showed definite reduction of blood sugar (23).

A flavonoid-rich fraction isolated from guava leaves was extracted, made into tablets with 400 mg of the concentrate in each, and administered at a dosage of 6-12 tablets each time, three times daily (total daily dose is 7.2-14.4 grams), to produce hypoglycemic action (17). The higher dose of 36 tablets per day is analogous to the use of Golden Book Tea Pills at 12 pills three times daily mentioned above.

Ginseng and its saponins have been studied in alloxan-treated, genetically diabetic, and normal mice (24), revealing a hypoglycemic effect; ginseng saponins also stimulate the production of insulin. In elderly patients with hyperglycemia, the saponins reduced serum glucose (25). Ginseng saponins are typically provided in tablets of 50 mg each, with a dose of 1-2 tablets each time, two to three times per day.

A preparation (method unknown) reported in an article in the Journal of Traditional Chinese Medicine (26) suggests that a condensed blend of herbs can be prescribed in moderate dosage. This article described treatment of 102 cases of non-insulin dependent diabetes, using the Gan Lu Xiao Ke capsule, with rehmannia, codonopsis, astragalus, ophiopogon, asparagus, scrophularia, cornus, tang-kuei, hoelen, alisma, and cuscuta. Patients were treated with the herbs for three months. The group average blood glucose level fell from an initial value of 200 mg% to 154 mg%. The dosage of material in the capsules was only 5.4 grams per day. However, the results were also modest (30% were markedly improved, 57% were improved, but the average blood sugar remained quite high), and patients would receive additional herbs to treat specific symptoms: those herbs, adding to the total dosage, might contribute to the hypoglycemic action.

Further investigation of the minimum formula size (number of ingredients and dosage of ingredients) to get the desired effects is necessary to assure a satisfactory level of compliance with minimal side-effects. When using isolated active components, one is often subject to adverse reactions, but, on the other hand, the complex formulas in high dosage can also cause problems aside from the unpleasant taste (and potential to cause nausea). For example, one difficulty with the high dosage decoctions is that they often contain a large amount of sugar which causes an increase in blood glucose during the hour after it is consumed (later, the herbs cause a gradual and sustained decrease). Rehmannia, codonopsis, and ophiopogon are examples of herbs with high sugar content. The other difficulty is that many patients resist regular consumption of very large dosages because of the inconvenience and high cost.

Using powdered crude herbs in place of decoctions or dried decoctions is often an option for treating functional disorders, but there is little relatively little precedent for this as applied to diabetes in Chinese medical practice, with the possible exception of the single herb ginseng and treatments for secondary effects of diabetes. This is likely because the amount of active ingredients that could be conveniently ingested in this form is not high enough.

There is a potentially promising example, however, from recent research which may suggest that powdered herbs in modest dosage can be used with some success. Persons with vascular complications of insulin independent diabetes (e.g., coronary heart disease, vascular disease of the lower extremities, stroke, retinopathy, etc.), were treated with a sugar-reducing pulse-invigorating formula (ingredients unspecified other than astragalus and rehmannia; the formula tonifies qi, nourishes blood, and vitalizes blood) in capsules of powdered herbs, at a dosage of 2-3 grams each time, three times daily (29). The treatment time was three months, and if the treatment was deemed effective, it would then be continued. Improvements in hemorrhology were noted in 82% of the cases marked by qi and yin deficiency (which the formula mainly addressed), but only about 63% for other cases (yin deficiency with fire, or yin and yang deficiency). Fasting blood sugar was maintained below 150 mg% for 77% of those treated.

While it is quite common in China to utilize very high doses of herbs in decoction, pill, or tablet form, in the West, this requirement usually causes poor compliance. Therefore, one would like to select the most effective herbs, prepare them in the most effective form, and provide them in the most convenient manner. According to the Chinese research, the minimal amount of dried extracts or powdered herbs to be consumed daily is in the range of 6-24 grams. Presumably, for a given formula within this range, the higher the dose, the more dramatic the hypoglycemic action.

COMBINING INSULIN AND OTHER DRUGS WITH HERBS

While Chinese literature sometimes mentions, in passing, the use of Chinese herbs along with insulin, specific strategies for combining the two are not commonly presented in English-language publications. A report on integrated Chinese and Western treatment of diabetes was published in 1987 (27). For insulin-dependent diabetics, a formula made with codonopsis, astragalus, atractylodes, rehmannia, ophiopogon, and lycium fruit was given (the formula tonifies qi and nourishes yin). For those with non-insulin-dependent type, they were treated with the same mixture either alone or with tolbutamide or glyburide. The herbs, prepared in liquid form, were given twice daily for three months. It was reported that the herbs exhibited a hypoglycemic effect and synergized with insulin and other drugs. For the group of 53 patients treated, the average fasting blood glucose at the beginning was 177 and at the end of the three months was 135.

In one clinical trial (18), a group of 10 patients was identified who had responded poorly to Western drugs and also failed to respond to Chinese herbs. They were then given both the herbs and drugs concurrently. Significant improvements were observed in eight of the ten patients.

Ginseng is reported to reduce the dosage of insulin needed by patients and to prolong the action of a dose of insulin (13).

EXPECTED OUTCOMES

According to a representative clinical evaluations mentioned in this article, about 70-80% of those using the appropriate formulations at the high Chinese-style dosages achieve some degree of improvement in their diabetic condition. Blood sugar levels may not reach the normal zone for many so treated, but they are reduced sufficiently to ameliorate symptoms and to decrease the risk of serious secondary effects of the higher blood sugar levels maintained over a long period of time. Still, 20-30% of patients may fail to respond or show only a marginal response. If the dosages are lowered, due to poor compliance with the protocols, the success rate is likely to be even less. Among those who showed some degree of improvement in the Chinese trials, there are certainly some responses which would be deemed inadequate to justify continuing with the herb therapy due to its inconvenience. These factors need to be taken into account when describing outcomes to diabetics who are about to begin a course of therapy.

It may be of greater interest, for many diabetics seeking the benefits of Chinese herbs, to pursue the treatment of complications of diabetes. For example, diabetic neuropathy has been reportedly helped by a modification of the Rehmannia Eight Formula (Achyranthes and Plantago Formula), which itself may contribute to lowering blood sugar and aiding insulin regulation. Similarly, diabetic retinopathy is treated by herb combinations, such as one reported in the Liaoning Journal of Traditional Chinese Medicine (28), that incorporate herbs helpful in lowering blood sugar (e.g., astragalus, rehmannia, scrophularia, salvia, pueraria, and atractylodes (cangzhu) along with some other ingredients aimed at the symptom (tang-kuei, chrysanthemum, eriocaulon, and laminaria), with reasonable success: about 80% of treated eyes showing improvement; plasma viscosity and blood sugar were also reduced.

One of the factors causing diabetic complications is believed to be increased aldose reductase activity. In a laboratory study of herbal inhibition of aldose reductase, it was shown that the active constituents of pueraria, scute, and sylibum, and the whole herb extracts of licorice, salvia, astragalus, gentiana, and cnidium had significant activity (31). Pueraria, salvia, and astragalus are frequently employed in modern Chinese herb treatments for diabetes.

Depending on the type of diabetic syndrome and other health factors, the use of the Chinese herbs would likely have to be continued for quite some time (the exception might be some cases of lowered insulin production, which could possibly be remedied by one or two months of therapy with herbs). However, positive effects on symptomatic manifestation of diabetes is reported to occur in the first few weeks of treatment. It is possible that after an initial high-dosage treatment to lower blood sugar significantly that a more convenient low dosage maintenance program could be used as follow-up.

In the most common type of diabetes, which has late onset, a combination of herb therapy, dietary control, and obesity reduction could result in the cure of diabetes (not requiring continued ingestion of herbs), though the tendency for it to recur as a result of weight gain, dietary indiscretion, or emotional stress would remain.

Along with Chinese herb therapy, acupuncture can be used to treat risk factors for diabetes (e.g., obesity), the diabetic syndrome, and the secondary effects of diabetes (7, 32). Further, the use of nutritional supplements (9) and Oriental dietetic practices (10) could greatly improve the outcomes attained by traditional acupuncture and herbal medicine. Unfortunately, the effects of a comprehensive program of treatment has not been studied, so the degree of effectiveness is not yet known. One can only suggest that the outcomes would likely be somewhat better than those reported in this article.

REFERENCES

1. Maoshing Ni, The Yellow Emperor's Classic of Medicine: A New Translation of the Neijing Suwen with Commentary, 1995 Shambhala, Boston, MA.
2. Hong-Yen Hsu and Su-Yen Wang (translators), Chin Kuei You Lueh, 1983 Oriental Healing Arts Institute, Long Beach, CA.
3. Hong-Yen Hsu and Peacher WG, Chen's History of Chinese Medical Science, 1978 Oriental Healing Arts Institute, Long Beach, CA.
4. Xie Zhufan and Huang Xiokai (eds.), Dictionary of Traditional Chinese Medicine, 1984 Commercial Press, Hong Kong.
5. Hong-Yen Hsu and Chau-Shin Hsu, Commonly Used Chinese Herb Formulas with Illustrations, 1980 rev. ed., Oriental Healing Arts Institute, Long Beach, CA.
6. Hong-Yen Hsu, Chinese herb therapy for diabetes mellitus, Bulletin of the Oriental Healing Arts Institute 1978; 3(1): 12-17.
7. Chen DC, et al., Clinical and experimental studies in treating diabetes mellitus by acupuncture, 1994 Journal of Traditional Chinese Medicine; 14(3): 163-166.
8. Clayman CB (ed.), AMA Encyclopedia of Medicine, 1989 Random House, New York.
9. Werbach, MR, Nutritional Influences on Illness, 1993 Third Line Press, Tarzana, CA.
10. Lu He, Chinese System of Food Cures, 1986 Sterling Publishing Co. Inc., New York.
11. Guo SS, et al., Changes in tongue color and whole blood viscosity in diabetics treated with Yiqi Yangyin Huoxue Fang, Journal of traditional Chinese Medicine 1989; 30(2): 97-98.
12. Han DW and Xu RL, Progress in the research of blood activation and hemostasis removal, Abstracts of Chinese Medicine 1988; 2(4): 466-483.
13. Hson-Mou Chang and Paul Pui-Hay But (eds.), Pharmacology and Applications of Chinese Materia Medica, (2 vols.), 1986 World Scientific, Singapore.
14. Zhu KY, Guo SS, Liang XC, Diabetes mellitus treated by traditional Chinese medicine, Journal of the American College of Traditional Chinese Medicine 1983; 1: 24-30.
15. Li Yucai, et al., Treatment of 33 cases of diabetic ketonuria with Jiang Tong Tang, New Journal of Traditional Chinese Medicine 1989; 21(2): 20-22.
16. Huang RL, et al., Studies on the antihyperglycemic actions of Chinese herbs, 1980-1984 The Annual Reports of the National Research Institute of Chinese Medicine, Taipei Hsien, Taiwan.
17. Wang Qi and Dong Zhi Lin, Modern Clinical Necessities for Traditional Chinese Medicine, 1990 China Ocean Press, Beijing.
18. Gao JZ, Treatment of diabetes with Shen Qi Tao Hong Tang, Journal of Zhejiang Traditional Chinese Medical College 1989; 13(1): 15-16.
19. Shang Xianmin, et al., Practical Traditional Chinese Medicine and Pharmacology: Clinical Experiences, 1990 New World Press, Beijing.
20. Dong Zhi Lin and Jiang Jing Xian, 100 Famous and Effective Prescriptions of Ancient and Modern Times, 1990 China Ocean Press, Beijing.
21. Zhang Junwen, et al., Integrating Chinese and Western Medicine: A Handbook for Practitioners, 1993 Foreign Languages Press, Beijing.
22. Chen Song Yu and Li Fei, A Clinical Guide to Chinese Herbs and Formulae, 1993 Churchill Livingstone, London.
23. Ni YX, et al., Clinical and experimental studies on the treatment of diabetes mellitus with berberine, Journal of Integrated Traditional and Western Medicine 1988; 8(12): 711-713.
24. Kimura M and Suzuki J, The pharmacological role of ginseng in the blend effect of traditional Chinese medicines in hyperglycemia, 1985 Advances of Chinese Medicinal Materials Research, World Scientific, Singapore.
25. Chen KJ and Zhang WP, Advances on antiageing herbal medicines in China, Abstracts of Chinese Medicine 1987; 1(2): 309-330.
26. An GY, et al. Treatment of 102 cases of non-insulin dependent diabetes mellitus with Gan Lu Xiao Ke capsule, Journal of Traditional Chinese Medicine 1985; 26(6): 431-432.
27. Yao QG, Integrated Chinese and Western treatment of 53 cases of diabetes, Chinese Journal of Integrated Traditional and Western Medicine 1987; 7(6): 363-364.
28. Li ZZ and Du BR, Treatment of 17 cases of diabetic retinopathy by qi benefiting, yin nourishing, stasis eliminating, and nodule dissolving method, Liaoning Journal of Traditional Chinese Medicine 1991; 18 (8): 19-21.
29. Lin L, et al., A clinical study on treatment of vascular complications of diabetes with the sugar-reducing and pulse-invigorating capsule, Journal of Traditional Chinese Medicine (English) 1994; 14(1): 3-9.
30. Dong Zhi Lin and Yu Shu Fang, Modern Study and Application of Materia Medica, 1990 China Ocean Press, Beijing.
31. Zhang JQ and Zhou YP, Research into the use of Chinese herbs which inhibit the mechanism responsible for diabetic ophthalmopathy, International Journal of Oriental Medicine 1992; 17 (3): 160-164.
32. Hu Y, Recent advances on diabetes mellitus in acupuncture and Chinese medicine, Oriental Healing Arts International Bulletin 1988; 13(2): 154-162.
33. Fegn JH, et al., 103 cases of diabetes mellitus treated by Jiang Tang Le, Journal of the Shangdong College of Traditional Chinese Medicine 1994; 18 (6): 376-377.