MANAGING TYPE II DIABETES EAST & WEST LORI KELSEY RN-BSN DOM.

Presentation on theme: "MANAGING TYPE II DIABETES EAST & WEST LORI KELSEY RN-BSN DOM."— Presentation transcript:

1 MANAGING TYPE II DIABETES EAST & WEST LORI KELSEY RN-BSN DOM

2 OBJECTIVES 1. How TCM ameliorates/ resolves Type II Diabetes [DMII]: herbs, nutrition, supplements 2. Help your practitioner(s) help you: Anticipate/plan finances, time, energy & lifestyle modifications for best results. 3. Give the herbs time to work: Success depends on dose & length of time on herbs 4. Efficiently coordinate care: Success depends on treating root causes- East & West

3 CHALLENGES vs. BENEFITS  Oral hypoglycemics have side effects [liver, kidney, GI], and decrease HbgA1c only up to about 2.0 points.  Chinese herbs can eliminate the need for high doses, additional meds, and/or insulin. No side effects.  Large volume of herbs required to effectively address signs & symptoms of DMII- Dose-dependant!  10 days -> 3 mos-> 9 mos to stabilize a chronic disease.

4 PLANNING TX & GOALS  Different herbs act differently : insulin production & resistance, LV gluconeogenesis etc.  Pattern discrimination: determines best herbal formula(s) for an individual.  Measures of Tx success : Resolution of certain S/S [e.g. neuropathy] Regulated FBGL, PP BGL, HS BGL, RBGL Normal Metabolic Screens [LDL, HDL, T Chol, HOMA] Compliance with lifestyle modifications.

5 RESPONSIBILITIES patient & provider  Help patient manage cost of Tx raw vs. granules vs. pills/patents determines cost, practicality & efficacy.  Bring medical records labs results, imaging, logs etc.  Update providers about changes in health status, medications, how you feel [both Eastern & Western].  Talk to your practitioner about concerns or problems with the plan of care.  DOCUMENT Tx plan & results.

6 RESPONSIBILITIES patient & provider DO NOT Stop Diabetic Meds Abruptly! “Herbal & drug treatments should overlap for 1 to 2 weeks before patients begins tapering off their drugs, in order to ensure adequate control of blood glucose levels”. Chen PharmD, LAc- Evergreen Herbs

7 DMII diagnostic criteria Fasting Blood Glucose Level [FBGL] >126 two times. HbgA1c >6.5 Glucose Tolerance Test [ GTT ] BGL >200 2hrs after 75gm of oral glucose. Random Blood Glucose Level [ RBGL ] > 200 + s/s:  The 3 P’s [ polyuria, polyphagia, polydipsia ]  Weight loss  Hyperosmolar hyperglycemic state [ BGL > 600, stupor, coma ]

8 DIABETES definition A group of acquired or genetic metabolic diseases characterized by hyperglycemia due to defects in insulin secretion, action, absorption into cells [or all three].  DMI no insulin produced, requires insulin injections.  DMII insulin resistance + excessive insulin secretion -> progressive decline in insulin secretion.  Gestational Diabetes [GDM] risk for DMI & DMII.  Diabetes Insipidus excess urination & thirst for reasons other hyperglycemia [non sweet-tasting urine].

9 DIABETES genetic  B cell [pancreatic cell] dysfunction  Leprechaunism – fatal in infancy  Rabson-mendenhaul syndrome - teeth, nails, pineal  Down’s syndrome  Klienfelter’s & Turner’s syndrome

10 DIABETES disease  Cystic fibrosis  Pancreatitis/ pancreatectomy  Cancer  Hemochromatosis  Agromegaly  Cushings  Glucagonoma  Phenochromatoma  Hepatitis C www.cdc.gov/hepatitis/RiskAssessmentwww.cdc.gov/hepatitis/RiskAssessment

11 DIABETES drugs/medication CV - thiazide diuretics, beta blocker HIV/AIDS Steroids Dilantin Interferon Nicotinic acid / niacin/ B3

12 DIABETES immune reaction  Rubella  Cytomegalovirus  Anti-insulin receptor antibodies  Stiff- man syndrome  Pancreatic beta cell destruction

13 DIABETES infections/ inflammation  Urinary Tract  Dental/ periodontal  Respiratory tract  Any infection/ inflammation

14 nip PRE-DIABETES in the bud  Impaired Glucose Tolerance [IGT] BGL >200 2 hr PP  Impaired Fasting Glucose [IFG] >110 but <126  Prevent End Organ Damage micro/macro circulation changes have already begun!  Lifestyle Changes diet & exercise, supplements, stress management, fixing chronic inflammations/infection.  Chinese Medicine : acupuncture, herbs, food-as- medicine, qi gong, bodywork etc.

15 METABOLIC SYNDROME what? Insulin Resistance [IR] may /may not be diagnosed with DM II… YET! + Hypertension [tai yang body type] Dyslipidemia [DM II -> inc TG & LDLc, dec HDL] Abdominal obesity [inc waist-to-hip ratio, tai yin body type] Protein in urine [renal insufficiency, shao yin body type]

16 INSULIN RESISTANCE why?  Obesity [BMI > 3.0]  Sedentary : 10” of aerobic exercise is beneficial [150” of moderate exercise per week recommended- trampolene ]  PCOS : related to metabolic syndrome  Genetic s: e.g. Rabson-mendenhaul syndrome  Inflammation / Infection : periodontal, UTI  NAFLD…

17 METABOLIC SYNDROME NAFLD… Non-alcoholic fatty liver disease [NAFLD] is considered the hepatic component of metabolic syndrome with insulin resistance [IR] the pathological hallmark! One third of people with NAFLD have Metabolic Syndrome. www.ncbi.nlm.nih.gov/pubmed/20370677 Patric, 2014

18 …NAFLD WHY?  High fructose corn syrup [HFCS] => obesity  Obesity => NAFLD => IR => DMII  Drugs glucocorticoids, anti ‐ estrogens, synthetic estrogens, aspirin, calcium channel blockers, Depakote, cocaine, anti- neoplastic  Hepatotoxins petrochemicals, and organic, solvents in cigarette smoke, paint, pesticides, dry cleaning.  Rapid weight loss  Gastric bypass surgery  HIV & HIV drugs  Metabolic Diseases (lipodystrophy)

19 BLOOD SUGAR goal HbgA1c < 6.5 > 6.5% if comorbidity or risk for hypoglycemia < 7.0 if diabetic Fasting < 126 Random < 200 Pre-meal 70 to 130 [80 to 120] 2 hr post-meal < 180 [target goal if HbgA1c is not at goal]

20 LDL goal Optimal<100 [<70 if diabetic] Near optimal 100-129 Borderline 130-159 High 160-189 Very high >190

21 CHOLESTEROL goal Desirabl e < 200 Borderline200-239 High>240

22 TRIGLYCERIDE goal [niacin, omega 3 fatty acids] Normal<150 [especially if diabetic] Borderline 150- 199 High 200 – 499 Very high >500 [>1000 = risk for pancreatitis]

23 HDL goal [exercise] Optimal > 60 [1point off risk assessment] Borderline 40-59 M 50-59 F moderate reduction if F may indicate an insulin resistance syndrome High to very high- risk[bad ] < 40 M < 50 F

24 BLOOD PRESSURE goal Normal< 120/80 optimal < 140/90 if diabetic [<130/85 optimal] < 150/90 if 60 yrs old or older Pre hypertension120 to 139 / 89 to 90 Stage 1140 to 159/ 90 to 99 Stage 2>160 / >100

25 SCREENS PQRS  Dyslipidemia [specifically LDL level]  Blood pressures  Urine albumin [renal impairment]  Foot exam [monofilament test for peripheral neuropathy] Physician’s Quality Reporting System from Centers for Medicare and Medicaid

26 SCREENS HbgA1c Average blood sugar level over past 3 months Lower HbgA1c => Lower risk for DMII complications www.accu-chek.com/us/glucose-monitoring/a1c-calculator.html# www.accu-chek.com/us/glucose-monitoring/a1c-calculator.html#

27 SCREENS Framingham score Risk of a cardiovascular event within the next 10 yrs. Based on age, gender, SBP, cholesterol, smoking status + 2 risk fx for CVD (smoking, Low HDL, FHx of early CVD, >45M, >55F Risk increases significantly with uncontrolled DIABETES! http://cvdrisk.nhlbi.nih.gov/calculator.asp

28 SCREENS body mass index [BMI] Based on weight vs. height medication dose decreases up to 50% With minimal weight loss [1-3 lbs] 7% of body weight is recommended

29 SCREENS HOMA-IR Homeostasis Model Assessment of Insulin Resistance  HOMA-IR is calculated using FBGL and serum insulin level Pancreatic beta cell function & insulin sensitivity are proportional to FBGL.  Healthy HOMA = 0.5 – 1.4 <1.0 HOMA-IR = optimal insulin sensitivity >1.9 HOMA-IR = early insulin resistance >2.9 HOMA-IR = significant insulin resistance  FBGL [ HOMA-IR < 1.4  Insulin resistance factors are used to calculate insulin regimens  www.dtu.ox.ac.uk/homacalculator/index.php www.dtu.ox.ac.uk/homacalculator/index.php  www.thebloodcode.com/homa-ir-calculator/ www.thebloodcode.com/homa-ir-calculator/

30 SCREENS NAFLD  GGT 10 -15IU+ [NAFLD is likely if >35IU]. Indicates risk for DMII  ALT 19.5+[ NAFLD is likely if >30]  Insulin 10+  TG 100+  BMI 25+  Waist circumference [ WHR ]  NAFLD Fibrosis Score [age, BMI, AST, ALT, PLT, ALB, DM status] www.nafldscore.com www.nafldscore.com (Patrick, 2014)

31 SCREENS other Apolipoproteins [apoB] transports LDLc with high levels associated with CVD. Measured when TG are >150 or HDL-C is <40 CRP & LpPLA2 are markers of inflammation

32 DIABETES complications  EYES : cataracts, glaucoma, AMD, retinal hemorrhages  GI: idiopathic diarrhea/constipation, gastroparesis,  GU/RENAL : chronic UTI, renal failure, renal HTN  REPRO : ED, vaginal dryness, yeast infx, infertility/PCOS  SKIN : changes, discolorations, infections, blisters/ulcers  on the feet, gangrene, itching, eczema, acanthos nigrans  NEURO / autonomic : gastric motility, ED, incontinence  overactive bladder, cardiac [can’t feel chest pain],  CARDIOVASCULAR : MI, stroke, HTN, dyslipidemia, neuropathy  PSYCH: depression [especially if on dialysis]

33 DRUGS west Sulfonureas [Glyburide, Glipizide] Inc insulin secretion Meglitide [Prandin, Starlix] Inc insulin secretion Biguanides [Metformin] Dec glucose production. Inc glucose uptake A-Glucosidase inhibitors [Glyset] Dec carbohydrate digestion/absorption Thiazolinediones [Actos, Avandia] Inc glucose uptake Dipeptidyl Peptidase-4 Inhibitors [Januvia] Inc insulin secretion. Dec glucagon secretion

34 HERBS east Chinese herbs [and the micronutrients in them] can address most of the aspects of Type II Diabetes. AND mimic the action of the oral drugs. But to what extent… Will less cost of drugs offset cost of herbs… On herbs forever…

35 DIABETES XIAO KE WASTING & THIRSTING POLYDYPSIA = thirst = upper xiao ke = LU POLYPHAGIA= hunger = middle xiao ke = ST POLYURIA= urination = lower xiao ke = K

36 POLYDYPSIA thirst upper xiao ke Prototype formulas treat LU heat & dryness [thirst] Xiao Ke Fang Asparagus and Ophiopogon Decoction [hyper & hypoglycemia]

37 POLYPHAGIA hunger middle xiao ke Prototype formulas treat ST fire [ excess ] or ST yin xu [ deficiency ] Jade Woman Decoction [excess] Jade Fluid Decoction [deficiency] Contains Ji nei jin- used for pernicious anemia/vitamin B12 deficiency Zhen Ye Tang [hypergycemia d/t hyperthyroid or excess cortisol/stressl]

38 POLYURIA urination lower xiao ke Prototype formulas treat K/LV yin [emaciation]-> LV qi [renal HTN] -> K yang [K insufficiency ] Six-Ingredient Rehmannia Pill Pulse-Activating Powder Kidney Qi Pill renal failure patients generally not prescribed herbs because of the toxin buildup. They need dialysis.

39 regulate BGL HERBS  FBGL : rou gui, shan zha, shan zhu yu, nu zhen zi, lychii, reishi, ginger, fenugreek, sanqi, pumpkin, huang qi, da huang, ge gen, sheng di/shu huang, huang jing/ Hu Zhang, yu zhu, panax ginseng, tea.  Post prandial BGL, shan zhu yu, huang bai, huang qin, fenugreek, ginseng  Enhance Glucose uptake : rou gui, da huang, schizandra, ge gen  Enhance Insulin sensitivity : huang qi,  Decrease Insulin resistance: schizandra  Enhance Proliferation of pancreatic Islet cells – shan zhu yu  Enhance regeneration of pancreatic cells : gymnema  Decrease pancreatic B cell death : huang qi, ginseng, schizandra fruit  Protect pancreatic cell : shan zhu yu  Enhance Glycogen storage : huang qi, yu zhu, fenugreek, gymnema  Decrease glucose synthesis [gluconeogenesi ] : huang jing/ Hu Zhang  Enhance Insulin release : aloe vera, pumpkin, huang qi, reishi, gymnema  Decrease Insulin release : rou gui, shan zhu yu, ginger, ge gen, cassia, tea (Yin, Zhang & Ye, 2008), (Wang, Wang & Chan, 2013)

40 regulate BGL HERBS  Huang Qi 30 – 60gm daily for fatigue, regulates BGL [both hypo & hyperglycemia].  Shan Yao 100 – 200gm daily. Decoction form minimizes carbohydrates/ glycemic index and the resultant sugar conversion problems.  In Bu Zhong Yi Qi Tang or Ba Zhen Tang. Major formulas to tonify qi.  Basic herbs & formulas for recovery from chronic disease

41 regulate BGL HUANG QI Broad spectrum of effects [see source list] Animal Studies  500mg/kg decoction daily x 2 mos improved insulin sensitivity & NAFLD  Reduced BGL, indirectly preserved pancreatic cell fx and mass via immunomodulation.  Improved insulin-resistance after 6 weeks  Reduce FBGL, albuminuria, reversed glomerular hyperfiltration, ameliorated pathological changes of early diabetic nephropathy. Human Studies  Numerous studies on protective affect against diabetes-related nephropathy, renal hypertension, and vascular endothelial cell damage etc (Xu, et al., 2012) (Zhang, Xie, Li, & Fu, 2009)

42 regulate BGL HUANG QI  Lowers BGL prevents complications related to DM.  Protects kidneys [ Iarge dose, 20-60g daily].  Boosts qi [cAMP & microcirculation], mildly promotes urination, benefits diabetic ulcers in combination with other herbs.  Consolidates wei qi = immunity preserves CD8 T- lymphocyte telomeres- prolonging cell life. Telomeres are protective regions at the end of chromosomes that shorten each time a cell divides.

43 regulate BGL SHAN YAO A Chinese food product traditionally used to lower blood sugars. Chinese herbal pharmacists state that with the new technology, the granular [processed form] works just as well. In a recent study 150g daily lowered blood sugar levels in 10 days. Since it is expensive, 50 gms is the usual dose. However the extent of the blood sugar reduction may be dose-dependant.

44 regulate BGL SHAN YAO Root contains 0.012% diosgenin a phytoestrogen that can be converted in a lab to pregnenolone, progesterone, cortisol, DHEA and other steroid hormones Wild Yam Extract containing 4, 6, 10, 20% diosgenin - > dec mass & weight of adrenal cortex and medula in rats -> may lead to major endocrine dysfunction.. H ormone-sensitive & protein S deficiency Caution? Risks isolating Chinese herbal constituents!!!

45 regulate BGL HERBS Shan Zhu YU dec micro albumin in diabetic patients Di gu pi peak affect in 3 to 4 hrs x 7 to 8 hrs. Protects against NAFLD. Zhi mu dose-dependently inc glucose metabolism, glycogen synthesis; dec gluconeogenesis and/or glycgenolysis. Shu /Sheng Di huang redux LV glycogen Xuan shen less potent than di huang. Ze xie weak. Panax ginseng effective but not commonly used for DM due to cost? [Huang, 2009] [ Wang, & Chen, 2004]

46 regulate BGL Gymnema Animal Studies:  200mg/kg of leaf or callus extract = 4 U/kg insulin.  600mg/kg of acetone extract x 45 days dec BGL from 443 to 114mg/L.  5–20mg/kg showed significant effects on lowering BGL  Regenerates pancreatic cells, inc circulating insulin Clinical Trails:  200mg daily x 18 to 20 mos lowered HbgA1c, FBGL  500mg tincture x 3 mos dec hunger, fatigue, FBGL and PPBGL, HbA1c  Oral dose of 800mg daily dec FBGL 11% and HbA1c 0.6% (Wang, Wang & Chan, 2013)

47 regulate BGL Momordica/bitter melon Animal Studies: 400mg/kg: hypoglycemic, PPBGL, inhibited glucose absorption from GI tract Enhanced insulin sensitivity, lipolysis, inhibited gluconeogenesis Lab Studies:  Improved beta cell function, enhanced insulin excretion, and glucose uptake. Clinical Trails:  Poor methodology + non standardized herbal extractions -> contradictory results. (Wang, Wang & Chan, 2013)

48 regulate BGL Morus alba/ Mulberry Animal Studies:  8-weeks -> reduced insulin resistance  Leaf extract dose-dependently reduced FBGL, PPBGL, and glucosuria. Lab Studies:  Inc glucose uptake Human Studies:  Mulberry powder suppressed PPBGL surge  leaf/ sang ye, twig/ sang zhi, berry/ sang shen (Wang, Wang & Chan, 2013)

49 regulate BGL Fenugreek Lab Studies: Insulinotropic = inc peripheral glucose uptake Human Studies:  Extract dec BGL in both non-DM and DM patients  Meta-analysis showed 1.13% dec in HbA1C  Insulin levels were significantly higher (Wang, Wang & Chan, 2013)

50 regulate BGL Rehmanniae Widely used to treat diseases relating to blood, immune, endocrine, nervous, and cardiovascular systems in combination with others herbs. Animal Studies:  Rehmannia + ginseng, scutellariae, astragali->stimulated insulin secretion, pancreatic cell proliferation, improved diabetic ulcers. (Wang, Wang & Chan, 2013)

51 regulate BGL Stephania Human Studies:  Postulated to stimulates pancreatic insulin release.  Constituent: Fangchinoline 0.3–3mg/kg significantly decreased BGL, inc blood insulin.  Constituent: Formononetin in Huang Qi, potentiated the BGL-lowering effect, and increasing insulin level

52 regulate BGL MUSHROOMS Bai Mu Er/ Tremella Mushroom “Exhibited a significant dose-dependent hypoglycemic activity in normal Mice… The results suggested that EPS Exhibited considerable hypoglycemic effect and improved Insulin sensitivity… has potential oral hypoglycemic effect as a functional food for the management of DM “. Mushrooms As a Functional Food Mediator in Preventing and Ameliorating Diabetes (Perera & Li, 2011).

53 regulate BGL MUSHROOMS Ling Zhi/ Reishi Mushroom ”Dose-dependently lowered the serum glucose levels after administration in mice… The results strongly demonstrated the potential of GAE and CCE in combating diabetes in Experimental animals [34].” Mushrooms As a Functional Food Mediator in Preventing and Ameliorating Diabetes (Perera & Li, 2011).

54 regulate BGL MUSHROOMS Dong Chong Xia Cao/ Cordyceps Fungus “Significantly lowered the glucose level by oral administration in mice [53]… showed potent hypoglycemic activity in genetic diabetic mice… has multiple medicinal activities. The diabetic rats had significantly lower weight gain and higher blood glucose response in oral glucose tolerance test than the control rats… potential to be the functional food for diabetes [55]… may stimulate pancreatic release of insulin and/or reduce insulin metabolism [56]”. Mushrooms As a Functional Food Mediator in Preventing and Ameliorating Diabetes (Perera & Li, 2011).

55 regulate BGL MICRONUTRIENTS  B3 (Niacin) up to 100 mg. Positive effect on glucose tolerance*  B6 (Pyridoxine) 500-1000 mg. Regulates BGL, protects nerves.  Biotin 200-400 mcg. Enhances insulin sensitivity [mushrooms]  Flavonoids (mixed) 1-2 gm. Promotes insulin secretion & uptake.  Vitamin D 400-800 IU. Essential for proper functioning of pancreatic islets cells [mushrooms]. Severity of NAFLD.  Vitamin E 400-1200 IU. Improves glucose tolerance & insulin sensitivity [rosehips, eggs].  B5 (Pantothenic acid) 250-500 mg. Adrenal support [peas].

56 regulate BGL MICRONUTRIENTS  Chromium 150-200 mg. Improves glucose tolerance & insulin sensitivity.  Manganese 30-50 mg. Cofactor in glycemic control.  Potassium 300 mg. Maintains insulin sensitivity, secretion & responsiveness.  Zinc 100-150 mg. Improves insulin synthesis, secretion, utilization.  Spirulina 3-6 gm. Stabilizes BGL [cold thermal nature].  Vanadyl Sulfate 100-150 mg. Mimics insulin, improves cell sensitivity to insulin.

57 regulate BGL FOODS  European Blueberry (Vaccinium myrtillus)  Gymnema sylvestre / Jiao gu lan  Onion & Garlic  Cinnamon bark or twig / gui zhi, rou gui  Corn silk (Stima Maydis)  Buckwheat (Semen fagopyri cymosi)  Litchii fruit / li zhi he  Asian Pumpkin  All benefit BGL management in some way

58 other TCM Dx Blood Stasis... Blood Stasis is always a component of DM circulation & vascular problems Neuropathy, retinopathy, nephropathy, CVD, TIAs, ED 50% of people have neuropathy after 25 yrs neuropathy can resolve with BGL control Acupuncture often more effective than herbs for neuropthy

59 …blood stasis HERBS  Dan Shen invigorates blood systemically. Best for early stages of neuropathy. Response is poor if BGLs are very high. Gentle (no bruising/bleeding) video clip.video clip  Sanqi invigorates & regulates blood [retinal hemorrhage], c ardio-protective, cholesterol & BP lowering.  Niu Xi targets lower extremity circulation. Vascular complications of DM typically begin in the feet.  Huang qi gui zhi wu wu tang diabetic peripheral neuropathy  Ming mu di huang wan Retinopathy  Ban xia xie xin tang Gastroparesis  Saint John’s Wort oil-infusion nerve pain/ neuritis

60 …blood stasis MICRONUTRIENTS  B1 (Thiamin) 10 mg. Neuropathy, alcoholic neuropathy.  B2 (Riboflavin) 10 mg. Skin ulcers, eye & digestive problem  B12 (Cobalamin) 25 mcg. Normal nerve impulses.  Inositol 500 mg. Improves nerve function  Vitamin C 1000-4000 mg. Benefits eyes & nerves [ lipoic form is most bioavailabile-> no diarrhea, non acidic].  Calcium 1000 mg. Nerve transmission and pH balance [ Anhydrous aspartate form is more bioavailable].  Lecithin 3 Tbs. Benefits cell membranes, brain and nerves.

61 …blood stasis MICRONUTRIENTS  EFA-Omega 6 400-600 mg. Anti-inflammatory.  EFA-Omega 3 1 Tbs. Protection against hardening of arteries. improved insulin sensitivity, lower markers of NAFDL.  B15 (Pangamic acid) 50-100 mg. Antioxidant, helps atherosclerosis.  Magnesium 500 mg. Helps protect eyes. HOMA and Magnesium-deficiency related insulin-resistance x 25%,

62 …blood stasis Other  Light massage or warm compress x 30 minutes using a solution of 1 cup ACV in 2 cups of warm water to relieve lancing/burning nerve pain. Take care not to burn skin.  Other causes of neuropathy e.g. folic acid deficiency from certain drugs.

63 other TCM Dx Damp, Phlegm, Heat… Metabolic Syndrome Dyslipidemia [can resolves with BGL control] Atherosclerosis/ Arteriosclerosis Peripheral vascular /Cardiovascular disease Hypertension Obesity Acute and chronic inflammation/ infection Mood/ shen

64 …damp, phlegm, heat HERBS Prototypic Formulas for Metabolic Syndrome Er Chen Tang [ damp ] Wen Dan Tang [ phlegm ] Fang Feng Tong Sheng San [tai yang, yang ming, shao yin heat] HERBS BERBERINE- containing herbs… http://www.bioportfolio.com/resources/pmarticle/1253804/Efficacy-of-the-Wen-Dan-Decoction-a-Chinese-Herbal-Formula-for- Metabolic.html

65 …damp, phlegm, heat HERBS …Herbs containing BERBERINE for all aspects of Metabolic Syndrome  Huang Qin Comprehensive for LV/GB fat metabolism. Clears phlegm above the diaphragm, dries damp, clears all heat, drains fire/toxicity, calms wind, nourishes yin, subdues yang.  Huang Lian 200mg/kg extract significantly decreased BGL, cholesterol in high fat diet-fed mice. Very bitter, cold, drying but small doses => better digestion. Jian Pi Wan var. has 6 gms. Clears heat & fire, drains damp.  Both for middle xiao ke & post-prandial BGL elevation.

66 …damp, phlegm, heat BERBERINE  May inhibit sugar absorption from intestine and enhance insulin production without side effects at 2 gm daily.  DM I treated with Berberine 300-500 mg daily for 1 to 3 months (along with dietary control) ->  Definite reduction of BGL & FBGL  Decrease central obesity, insulin, HOMA, Chol, TG, LDLc.  Increase HDL, SHBG

67 …damp, phlegm, heat BERBERINE Oral Dose: 300, 400, 500 mg 3 times daily, adjusting dose according to BGL.  Less thirst & water consumption  Less urination  Improved strength/ energy  Lower BP  Symptoms declined with declining BGL

68 …damp, phlegm, heat BERBERINE  Blunted adrenaline-induced BGL inc [stress-response]  Activity was similar to sulfonylureas or biguanides  Insulin sensitivity  Improve fatty acid oxidation [prevents NAFLD]

69 …damp, phlegm, heat DYSLIPIDEMIA Niacin => lowers TG by 20% to 50%, increases HDL by 15% to 35%.  Immediate-release nicotinic acid 1.5 to 3gm  Extended-release NIASPAN 1-2 gm [Rx].  Sustained-release nicotinic acid 1-2 gm  Don’t overdose -> flushing & ST pain, increased BGL!

70 …damp, phlegm, heat DYSLIPIDEMIA  LDL : shan zha, sanqi, jie geng, cassia, tea  VLDL : shan zha  HDL : tea, ginger, reishi, lychii, rou gui,  T Chol : aloe vera, rou gui, shan zha, lychii, reishi, fenugreek, ginger, sanqi, pumpkin, ge gen, Chinese willow, cassia, tea.  TG : aloe vera, rou gui, shan zha, lychii, fenugreek  Absorption of GI fat : jie geng 1 dose at Bedtime: Cholesterol is synthesized at night

71 …damp, phlegm, heat DYSLIPIDEMIA  Oolong [neutral], black [warming], or green [cooling] tea after meals, to facilitate the digestion of fats.  Shan Zha digestion of fats & carbohydrates [as a beverage soaked in wine = jiu]  Apple Cider Vinegar softens the blood vessels, prevents atherosclerosis [sour flavor guides to the liver- place of lipid metabolism & recruitment]  Ginger tea SBP

72 …damp, phlegm, heat OBESITY Food-Combining Maximum use & distribution of digestive enzymes for complete combustion of food stuffs to reduce damp accumulation [fat] and enhance redistribution of ABD fat.  Protein + VEGETABLE (or) Carbohydrate + VEGETABLE  AVOID PROTIEN + CARBOHYDRATES together  Or minimize meat to flavoring/condiment w/ carbs  Medical Nutrition Therapy [e.g. very low carbohydrate diet VLCD] requires a specialist.  Drugs & bariatric surgery for BMI >35 + DM

73 …damp, phlegm, heat OBESITY Bojemni Tea  No significant studies proving the efficacy of this OTC tea for weight management.  Literally translates to “maintain health & appearance, reduce fleshiness”.  Used in China for 20 years to enhance digestion, remove damp & phlegm [lipids & adipose], food accumulation, mild laxative.

74 …damp, phlegm, heat OBESITY AVOID HIGH FRUCTOSE CORN SYRUP [HFCS] poorly metabolized compared to cane sugar quickly converted to adipose Unsweetened tea instead of Soda! Sweeten with cane sugar, or stevia HFCS => Obesity => NAFLD => IR => DMII

75 …damp, phlegm, heat OBESITY Pre/Probiotics  Modulation of gut microbiota to manage obesity.  Benefits insulin resistance, NAFLD & SBO [ small bowel bacteria overgrowth] to unburden the LV, an organ involved in maintaining normoglycemia, carbohydrate metabolism, protein synthesis.  Minimum of ____ colony-forming-units [CFU] to include bifidobacterium, lactobacillus ssp, fructo-oligosaccharide  Cultured/ fermented foods contain pre/probiotics www.ncbi.nlm.nih.gov/pubmed/25659049

76 …damp, phlegm, heat OBESITY  Raw Sauerkraut. Potent in CFU per Tbs. Must be raw and/or cultured cabbage [e.g. kim chi, “Bubbie’s” brand, homemade. Garden ripe cabbage. http://articles.mercola.com/fermented-foods.aspx http://articles.mercola.com/fermented-foods.aspx  VSL#3 pre/probiotic cited in research studies, and guidelines of medical gastroenterology associations [e.g World Organization of Gastroenterology]. Purchase at VSL3.com or Amazon.com for about for $53. www.vsl3.com/hcp/scientific-info/ www.vsl3.com/hcp/scientific-info/

77 …damp, phlegm, heat OBESITY Shen qu / Massa medica [in Jian Pi Wan var].  Fermented wheat flour, bran, qing hao/artimesia annua, xing ren/apricot kernel, cang er zi/xanthium, chi xiao dou/ mung bean, bai zhu/angelica ssp, and ?.  Overindulgence starch, alcohol & grains => glomus  Aids digestion, absorption of minerals  Boosts the SP, phlegm & mucous, water & food stagnation.  WHY NOT USED FOR DMII? WARM thermal nature -> C/I in ST yin deficiency & ST fire

78 …damp, phlegm, heat EXCESS/ DEFICIENT Too little COOLING calming anabolic YIN Too much WARMING stimulating catabolic YANG IMBALANCE ACID-BASE INFLAMMATION > infection PSNS vs. SNS Hormones [e.g. estrogen: progesterone] Thyroid [hyper vs. hypo] Adrenal [high vs low cortisol] cAMP vs cGMP

79 …damp, phlegm, heat EXCESS/ DEFICIENT  Shi Gao + Zhi Mu + Tian Hua Fen heat, BGL, thirst. Bai Hu Tang contains all three.  Sheng di Huang insulin production & sensitivity  Di gu pi [50g] + Gou ji zi cooked in 500mg of water. Common tea in parts of China to regulate BGL.

80 …damp, phlegm, heat EXCESS/ DEFICIENT Xuan Shen heat, fire/toxicity, dryness, yin xu  Lowers BGL [ 16% x 5hrs] & BP  Chronic neurogenic CV STRESS!!!  INFLAMMATION [capillary permeability, COXI & II, LOX] Steroids => inhibit COXI, II & LOX, but increase BGL significantly! Topical & inhaled steroids do not have this systemic effect. However the drug inset for Nasocort states that it can inhibit healing processes after physical injury or trauma- inhibits growth factor –> impairs self-healing.

81 other TCM pattern TOXIC HEAT/FIRE… Address INFECTIION/ inflammation ! Otherwise blood sugars may never be truly controlled. Diabetes is both caused by and/or exacerbates inflammation. Dental / periodontal disease and chronic urinary tract infections are notorious infections. Both can be occult / asymptomatic- meaning you may have either one and not have Any symptoms other than uncontrollable blood sugars. Add Bacterial vaginitis and chronic prostatitis to the list.

82 … toxic heat/fire HERBS Skin, urinary & vaginal infections  Xuan Shen clears heat, purges fire/toxicity  Ma Chi Xian (purslane): e-coli, proteus. Topically & internally. Common weed in New Mexico.  Pu Gong Ying [dandelion]: most gm+ bacteria, S. aureus, Strep hemolyticus.  Calendula homeopathic 30c p.o. daily for diabetic ulcers  MRSA Medi-Honey, Mercy Soap & Gel Medi-Honey Mercy Soap & Gel  Pharmacies sell products to screen for UTI

83 … toxic heat/fire HERBS Huang Qin / Scutellariae/ Scute Synergistic with beta-lactam antibiotics [ampicillin, amoxicillin, cefotaxime] to restore their effectiveness against beta-lactam resistant Staphalococcus aureaus and MRSA. At the same time used for hypersensitivity reactions, especially those r/t food sensitivity

84 … toxic heat/fire HERBS  Yin Care Supreme Oral: Chinese herbal rinse. www.yincare.com www.yincare.com  Oil-pulling : 6 gtt of oregano EO in 1 oz of sunflower oil [1% dilution]  Dr. Hilga Clark’s Oregano Tooth Powder. www.drclarkstore.com www.drclarkstore.com  Young Living Essential Oil dental care products

85 DIABETES depression It is a PQRS quality measure to screen all diabetic patients [especially those on dialysis] for depression. Standard of care is to screen only if there is access to proper treatment and follow-up, which may include TCM…

86 DIABETES depression Prototype formulas for phlegm & qi stagnation wen dan tang Huang lian wen dan tang Ban xia hou po tang Empirical herbs for GB Phlegm-heat disturbing the H [Dr. Chang] Tian Zhu Huang Shui Zhi / hirudo /leech Zhu ru/ Bamboo Zhi Shi Proprietary formulas for Gut-Brain connection Spirit Pearls & Cinnamon Pearls from ITM

87 DIABETES depression  LV qi yu: Chai hu su gan san  Ht/LU yin xu: Bai he di huang tang + Gan mai da zao for 2 months and then reduce dosage  Qi/blood stagnation: Xue fu zhu yu tang  HT yin xu: Tian wang bu xin dan  Ht/SP xu + qi/blood xu: Gui pi tang

88 MICRONUTRIENTS cautions  Avoid supplements containing cysteine=> interferes with uptake of insulin by cells.  Avoid fish oil containing large amounts of para- aminobenzoic acid (PABA) => elevates blood sugar.  Avoid extremely large dosages of vitamins B1 or C -> may inactivate insulin. (Choate, 1998).

89 MICRONUTRIENTS multivitamin/mineral Herbal MVI/MMI obtained by eating: Rosehips Kelp/ sea vegetable Watercress Dandelion root/ leaf Mushrooms Raw chocolate/ cacao Sprouted seeds/ grains Cultured/fermented foods [e.g. sauerkraut, tofu, kefir]

90 DMII Chinese Herbal Medicine Safe & effective when prescribed by a qualified practitioner! Herbal Apothecaries/Pharmacies compound custom herbal formulas.  Two Red Brothers, Herbs Etc., Taos Herb Co. [Tico’s]  Tronex, Crane Proprietary Patents/Pills : Evergreen Herbs / Dr Chen PharmD, LAc  Equilibrium for DMII  Kidney DTX for DMII with renal insufficiency  Cholisma ES for dyslipidemia and NAFLD  Flex NP for peripheral neuropathy AmericanDragon.com Look-up your condition and herbs/formulas Consult before buying herbs/formulas online ! wrong herbs, contaminants, unknown ingredients, poor quality & customer service.

91 DMII Example Tx Plan & Cost Cholisma + Huang Qi 30g & Shan Yao 100g daily x first 10 days Cholisma contains Xuan Shen for elevated BGL due to chronic stress. then Equilibrium + Cholisma x next 3 to 9 months + Bu Zhing Yi Qi Tang [depression etc. r/t SP qi falling] EST. HERB COST $100 x first mos. $65/mos x next 3 months. Then revaluate maintenance herbal Tx plan x next 6 months. Base on severe scenario of uncontrolled BGL + metabolic syndrome + complications.

92 …teas tinctures XIAO KE SP/ST xu [ fatigue ]  30g huang qi  100g shan yao SP/K yin xu [ weakness, emaciation ]  250g shan yao

93 …teas tinctures XIAO KE Thirst  125g tian hua fen/ trchosanthus Thirst + copious urine  2g sl sheng jiang  4.5g yan/salt  6g green tea Thirst + yin xu + CVD  15g bei sha shen/ glenhia  15g mai men dong/ oophiopogona  15g sheng jiang  5g yu zhu/ polygonati odorati

94 …teas tinctures XIAO KE Thirst + ST yin xu + damp-heat in LJ [inflammation]  50g wu mei/ umbeoshi plum Thirst + summer heat inhibits urine  10g dong gua pi/ benincaseae  10g xi gua pi/ watemelon rind  8g tian hua fen/ trichosanthus

95 …teas tinctures XIAO KE Obesity, cholesterol, HTN  15g shan zha + 12 he ye Obesity + tai yang body + LV symptoms + constipation  6g lu cha / green tea + 2g da huang Obesity + dyslipidemia + blood stasis  10g lu cha  10g he shou wu  10g ze xie  10g dan shen

96 …teas tinctures METABOLIC SYNDROME Blood stasis, phlegm, cholesterol, network vessel stasis [fluid retention, sores]  30g shan zha  10g yi mu cao/motherwort [H qi yu, diuretic, sores]  5g tea Blood stasis, cholesterol [CVD]  9g dan shen  3g green tea

97 …teas tinctures METABOLIC SYNDROME Blood stasis, arteriosclerosis, HTN 10g dan shen  10g raw hawthorne  5g mai men dong Prevent & treat angina, HTN, calms LV  5g ju hua/ crhysanthemum  10g raw shan zha  15g jue ming zhi / cassia

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102 SourcesSources Pre/Probiotics Gratz, S., Mykkanen, H., El-Nezami. H.(2010). Probiotics and gut health: A special focus on liver diseases. World Journal of Gastroenterology 16 (4), 403-410. Retrieved from www.wjgnet.com/1007-9327office. www.wjgnet.com/1007-9327office Kelishadi, R., Farajian, S., Mirlohi, M. (2013). Probiotics as a novel treatment for non-alcoholic fatty liver disease; A systematic review on the current evidences. Hepatitis Monthly 13 (4). Malaguarneraa, M., et al. (2010). Bifidobacterium combined with fructo-oligosaccharide versus lactulose in the treatment of patients with hepatic encephalopathy. European Journal of Gastroenterology & Hepatology 22 (2), 1999-206. Sigma Tao Pharmaceuticals. VSL#3: Scientific Info. Retrieved from www.vsl3.com/hcp/scientific- info/.www.vsl3.com/hcp/scientific- info/ World Gastroenterology Organization. (2011). Probiotics and prebiotics. Retrieved from www.worldgastroenterology.org www.worldgastroenterology.org

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