Part 2

In China, over the past 15 years, four large-scale diabetes surveys have been conducted, estimating that the prevalence of diabetes among adults is between 2% and 3%, with rates as high as 6% to 8% among those aged 60 and above. The total number of diabetic patients nationwide has exceeded 35 million; in addition, there are another 55 million people with impaired glucose tolerance (IGT). It is expected that, as living standards continue to rise, the incidence of diabetes will continue to increase. Therefore, strengthening diabetes prevention remains an important goal of China's medical prevention and control efforts. Diabetes falls under the TCM categories of “Xiaoke” and “Xiaoyang,” but Xiaoke does not necessarily equate to diabetes. Any condition presenting with polydipsia, polyphagia, polyuria, and wasting, such as hyperthyroidism or diabetes insipidus, also belongs to this category. Throughout history, medical practitioners have recognized through clinical practice that the onset of diabetes is related to congenital deficiency, emotional imbalance, dietary indiscretion, overwork, and external pathogenic factors, and believe that yang deficiency and dry heat permeate the entire course of the disease, manifesting clinically as lung dryness, stomach heat, and kidney deficiency, among other different syndromes. ① Congenital deficiency. The “Spiritual Pivot: Five Transformations Chapter” states: “People who are prone to Xiaoke and Xiaoyang, why do they suffer from these conditions...? Because all five organs are weak, they are easily afflicted by Xiaoke and Xiaoyang.” It also says: “People who frequently fall ill are often those whose bones, skin, and meridians are not strong enough, making them susceptible to pathogenic factors and thus prone to illness.” This shows that as early as 2,200 years ago, ancient Chinese medicine already recognized the significant role of congenital deficiency in the onset of Xiaoke disease. The “Spiritual Pivot · Root Chapter” further explicitly states: “When the heart is firm, the organs are stable and secure; when the heart is fragile, one is prone to Xiaoke and Xiaoyang heat.” “When the lungs are firm, one does not suffer from coughing and shortness of breath; when the lungs are fragile, one is prone to Xiaoke and easily injured.” “When the liver is firm, the organs are safe and hard to injure; when the liver is fragile, one is prone to Xiaoke and easily injured.” “When the kidneys are firm, one does not suffer from lower back pain; when the kidneys are fragile, one is prone to Xiaoke and easily injured.” This indicates that weakness of the five organs is the internal cause of Xiaoke. Among the five organs, the kidneys are the foundation of congenital constitution, the abode of primordial yin and yang, responsible for storing essence and regulating fluids. Kidney yin is the fundamental source of bodily yin fluids, playing a moisturizing and nourishing role for all organs and tissues; kidney yang is the fundamental source of bodily yang qi, providing warming and transformative functions for all organs and tissues. Therefore, congenital deficiency of the kidneys plays an even more important role in the onset of Xiaoke disease. When the body’s kidney essence is deficient, the function of containment declines, qi fails to transform water, and fluids flow directly into the bladder, resulting in frequent urination and intense thirst. As kidney yin deficiency further develops, yin damage spreads to yang, leading to kidney yang deficiency and failure of yang to transform qi, causing fluid to stagnate and resulting in the phenomenon of drinking once and urinating twice. Prolonged kidney yin deficiency inevitably leads to yin excess and yang excess, exacerbating the condition; moreover, since the six pathogenic factors take advantage of the weakness of the five organs to invade, the condition worsens and various complications arise. ② Emotional imbalance, liver qi stagnation turning into fire. As early as the “Spiritual Pivot · Five Transformations Chapter” it was clearly stated: “Anger causes qi to rise against the flow... and then turns into heat; heat damages the skin, thus causing Xiaoke.” The Qing dynasty famous physician Ye Tianshi said in “Clinical Guide to Medical Cases · Three Xiaoke”: “When the mind is filled with sorrow and depression, inner fire ignites, leading to severe Xiaoke.” This shows that long-term emotional discomfort, mental depression, and excessive expression of the five emotions—joy, anger, sorrow, grief, and fear—can lead to qi stagnation and blockage; prolonged stagnation can turn into fire, depleting body fluids and ultimately causing Xiaoke. The Yuan dynasty physician Wei Yilin said in “Effective Prescriptions of World-Class Physicians”: “Frequent irritability, constant worrying and overthinking, sadness and depression... heart fire rises, the lungs are completely affected, the mouth and tongue become dry, gradually developing into Xiaoke.” If extreme anger harms the liver, liver qi stagnates; then it transgresses to the stomach, affecting the spleen’s transformation function, causing the spleen’s qi to fail to ascend and the stomach’s qi to fail to descend, leaving food and nutrients trapped in the blood, thus resulting in Xiaoke. At the same time, the liver and kidneys share the same origin, and the child’s illness affects the mother, causing kidney water to be depleted, unable to ascend to the lungs or moisten the stomach, leading to lung dryness and stomach heat, causing thirst and frequent urination, with urine becoming thick and oily, ultimately developing into Xiaoke. ③ Overeating rich foods and alcohol, obesity. The “Plain Questions · Strange Diseases Chapter” says: “This person must eat sweet and delicious foods frequently and in large quantities. Fat makes people internally hot, sweetness makes people feel full, so their qi overflows and turns into Xiaoke.” As the saying goes, “Illness enters through the mouth,” and this is equally true for diabetes. Long-term overconsumption of sweet and rich foods damages the spleen’s ability to transform food and nutrients, leading to internal dampness and heat, which in turn damages body fluids; additionally, internal dampness intensifies stomach fire, burning yin and damaging it, spreading upward to the lungs and causing lung dryness and fluid depletion, resulting in thirst and frequent urination. Meanwhile, the heat burns the intestines, causing constipation and difficulty in bowel movements. The Qing dynasty physician Yu Jiayan expressed deep regret about how dietary indiscretion leads to Xiaoke, saying in “Medical Gate Laws”: “Fat and indulgence, rich alcohol and heavy flavors—how can one set limits! Over time, food and drink ferment into internal heat, body fluids dry up... the more one eats, the more thirsty one becomes, the more refined the diet, the more endless the hunger, and the more severe the Xiaoke disease becomes.” ④ Overwork and sexual impropriety. Excessive labor depletes the spleen’s energy and affects its transformation function, leading to qi deficiency. Overthinking also damages the heart and spleen, causing hidden consumption of yin blood and depriving the heart of yin nourishment, resulting in excessive heart fire that scorches lung fluids and leads to Xiaoke. Therefore, the Jin-Song dynasty physician Zhang Congzheng said in “Rituals of the Confucian Family”: “If you don’t reduce flavor, don’t restrain desires, and don’t moderate joy and anger, the disease will recur. If you can avoid these three things, Xiaoke won’t be a big concern.” Modern medicine believes that diabetes occurs on the basis of genetic susceptibility, combined with long-term environmental factors. There are significant individual differences in the causes of onset, the course of the disease, and the clinical manifestations. Modern research shows that whether it’s type 1 or type 2 diabetes, there is a clear genetic predisposition. According to comprehensive reports and analyses, 6.55% of Chinese diabetic patients have a positive family history; among those with a positive family history of diabetes, the incidence rate is 30 to 40 times higher than that of people without a positive family history, and the incidence rate among first-degree relatives (i.e., direct relatives) is 5 to 21 times higher than that of the general population. Relevant data indicate that 85% to 90% of first-degree relatives of type 1 diabetic patients also have type 1 diabetes, and the concordance rate for monozygotic twins is 54% for type 1 diabetes and 91% for type 2 diabetes, showing that both type 1 and type 2 diabetes involve genetic factors, with type 2 being more prominent. The genetic pattern of diabetes in China is mainly polygenic inheritance, with only a few families exhibiting single-gene inheritance. Currently, at least ten DNA loci are known to be involved in the onset of type 1 diabetes, among which the human leukocyte antigen gene (HLA) and the insulin gene are relatively well-defined. Among them, HLA-D and DR antigens are most closely associated with type 1 diabetes, especially HLD-DW₃-DR₃ and HLA-DW₄-DR₄, which have the strongest and most primary connection with type 1 diabetes. It is currently believed that the combination of HLD-DQA₅2 arginine residues and HLD-DQB₅7 non-aspartic acid residues constitutes the susceptibility gene for type 1 diabetes. Six genes are currently known to be associated with the onset of type 2 diabetes, such as the insulin gene, the insulin receptor gene, the glucokinase gene, the islet amyloid polypeptide gene, and mitochondrial gene mutations. However, whether it’s type 1 or type 2 diabetes, what is inherited is not diabetes itself, but genetic susceptibility to diabetes; the occurrence of diabetes still requires the participation of other factors. For example, viral infections are one such factor, including Coxsackie B₄ virus, rubella virus, mumps virus, encephalomyocarditis virus, cytomegalovirus, and others. These viruses can cause acute pancreatitis, damaging pancreatic β cells and leading to type 1 diabetes. Overnutrition and reduced physical activity are the main environmental factors contributing to type 2 diabetes; if body weight exceeds the standard weight by 20%, it is considered obese. If the waist-to-hip ratio is greater than 0.95 for men and 0.85 for women, it is called central obesity. Central obesity is closely related to type 2 diabetes and is strongly associated with insulin resistance. Clinical studies show that obesity can reduce tissue sensitivity to insulin, making the symptoms of type 2 diabetes more pronounced. Conversely, diabetic patients who are obese can improve their insulin resistance and diabetes symptoms by maintaining a reasonable diet and restoring their weight to normal. Therefore, a reasonable and scientific diet and maintaining a normal weight are effective measures for preventing and controlling diabetes. Certain chemical agents that are toxic to pancreatic β cells, such as tetrahydroxypyrimidine, streptozotocin, and rodenticide plimelin, can also cause diabetes; pentamidine, L-asparaginase, nicotinic acid, corticosteroids, thyroxine, diazoxide, propranolol, hydrochlorothiazide, phenytoin, α-interferon, and other substances can also affect insulin secretion, thereby inducing diabetes. Long-term mental stress or sorrow, or intense social competition and excessive work pressure, can all cause psychological trauma, leading to increased secretion of hormones that raise blood sugar and counteract insulin, thus inducing diabetes. Insulin resistance refers to the weakening of the physiological effect of the same amount of insulin; in this case, in order to correct metabolic disorders, pancreatic β cells may temporarily compensate by increasing insulin secretion, but this process quickly triggers downregulation, reducing the number of insulin receptors and further exacerbating insulin resistance, ultimately leading to diabetes. In addition, research has found that pancreatic β cells, while secreting insulin, also secrete the same amount of amyloid substance—amylin. Excess amylin is phagocytosed by lysosomes within the β cells, but it is not easily broken down by proteases; instead, it accumulates in the form of amyloid protein inside the β cells and damages them. When pancreatic β cells are damaged to a certain extent, clinical symptoms of diabetes appear. In summary, type 1 diabetes occurs because, on the basis of genetic susceptibility, pancreatic β cells, under the influence of viruses or certain pathogenic factors, trigger autoimmune reactions and cause the disease; whereas type 2 diabetes occurs when, on the basis of genetic susceptibility, pancreatic β cells, under the influence of certain pathogenic factors, develop insulin resistance.

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