Chinese Medicine assignment: Five elements of Acupuncture

Question

Task: What are the five elements of Acupuncture that can be reported on this Chinese Medicine Assignment

Answer

Case History 4 19.2

Question 1:prepare a Chinese Medicine assignment diagram on diagnosis that includes CF and symptoms, relevant aetiologies and appropriate links between boxes

Figure 1: Diagram on diagnosis that includes CF and symptoms, relevant aetiologies and appropriate links between boxes
(Source: Created by the researcher)

Question 2: Treatment Strategy

Treating the CF in Tennyson’s case with a detailed discussion of impact of CF treatment and patterns to consider for the treatment priority with proper reason

The patient displays symptoms of deficiency (Xu) with the exception of his Spleen Qi Xu with Dampness.Deficiency which is denoted with insufficient Qi and Excess is the accumulation of Dampness.Research conducted during this Chinese Medicine assignment reveals it is a mixed condition where both deficient and excess is considered (Xu and Shi).

In the last 24 hrs. he has had intermittent bouts of External Pathogenic Damp-Cold, which is an Excess condition (Shi).

Constitutionally as well as historically, he has deficient Lung and Wei (Defensive) Qi due to being a Metal CF. Contracting whooping cough was also observed during his childhood. His more acute bouts of diarrhoea are stemming from External Pathogenic Damp-Cold, which is entering his body easily because of his weak Wei (defensive) Qi. At other times his more chronic diarrhoea stems from a deficiency of Spleen and Kidney Yang, which are fuelled by his poor diet containing too many sweet, raw, cold, and damp-forming foods. The cold damp climate in which he lives further affects his health and leads him to crave the sun.

There are signs that he may have Lower Jiao Wasting -Exhaustion of Kidney Yin and Jing Xu due to his thirst and excess drinking (polydipsia) and his frequent and increased urination (polyuria) (CICM, 2019), even though the tongue and the pulse do not indicate Heat or Dryness due to the cooling and moistening effect of the Metformin.

In terms of Chinese medicine, diabetes mellitus usually corresponds to thirsting and wasting disease (Gascoigne, 2001, p299).Due to subjects’ excessive intake of sweet and greasy food, internal heat is generated, and this heat damages the Yin. With regard to the case study reviewed on this Chinese Medicine assignment, due to his diabetes, heat would have been mitigated by taking the drug namely Metformin, which helps to reduce blood glucose levels and enabling the cells to utilise glucose, might be interpreted as both clear heat and nourishing Yin” (Stephenson, 2016, p406).

If the treatment is not progressing, I would tap for Aggressive Energy because he has a serious illness, he is experiencing emotional stress and by taking Metformin (CICM, 2019, p135). As mentioned in the case study that Tennyson is also ‘undergoing heavy drug therapy’. The BNF (2016)indicates that diarrhoea is one of the side effects of taking Metformin and in Chinese Medicine; this could be considered an aggravation to treatment. Metformin is not licensed for use in the US (Gascoigne, 2001, p299) as some people develop a potentially life-threatening acidotic reaction.

If Aggressive Energy was present on the firsttreatment, then it is best to recheck it the next treatment to make sure that it has all been cleared. Occasionally, more Aggressive Energy comes up after the first drainage. Provided that it has been fully cleared at each treatment, this is unlikely to happen more than once or twice (CICM,2019).

Treating Metal CF is very important because, “The CF is the patient’s most underlying imbalance, and treating it alone is the simplest and often most elegant way of treating it. It would often address most of the symptoms if not all as mentioned in the Chinese Medicine assignmentcase study of Tennyson’s medical history, and this would give a proper pattern of diagnosis. It is therefore logical to begin treating the patient on the CF unless there is a good reason of not doing so(CICM, 2019).

Treating with CF is a good option to opt for because this will help him to feel more worthy, to feel connected and completeand be happier about his own skin. CF will help to get rid of the skin problems. Particularly issues such as feelings of loss, sadness, grief, sensitivity to rejection due to his fragile nature, as well as his tendency to be critical, not only of himself but also of others, can be well treated by choosing this particular treatment option. The feeling of emptinessis very common for Metal CF’s.He has always felt inadequate in society because of his identity as a black guy and felt that he wasn’t given positive acknowledgement.He is also grieving for not being a father.They just get stuck and find it difficult to let go and move on. According to Chinese Medicine, when the Lungs are weak, Metal CFs can be thin-skinned and delicate due to the Lungs being the ‘fragile’ or ‘tender’ Organ(Hicks, Hicks & Mole, 2011, p144). If Lungs were strong, he would physically be protected by his Lung’s defensive Wei Qi, and psychically by the Po, the mental-spiritual aspect of the Lungs. Without this defence, the patient could well be feeling a lack of self-worth, particularly when trying to identify with an absent father from the age of nine and the eventual loss of his father ten years ago. Metal types come from the father and may cause some grief creation as found in case of Tennyson when he lost his father and could not go to his funeral. This applies to Tennyson, as he ‘still regrets not trying to go to the funeral’. One function of Wei Qi, which “flows between the skin and the muscles, is to ward off external ‘evils’ or pathogenic factors such as Wind, Cold and Damp. At the same time, however, it nourishes the skin and thus the quality of the skin depends on having good quality Lung Qi” (Hicks, Hicks & Mole, 2011, p135).

Chinese Medicine assignmentresearch also reveals that Type 2 Diabetes is a progressive condition and usually gets worse over time if left untreated. Lifestyle changes with dietary advice and exercise are crucial to managing the condition. Ifthe patient is diligent with putting lifestyle advice into action, then just continuing to treat the CF may improve many of his symptoms and would make him feel better in himself. If the dampening effect of the Metformin and the coldness of the winter months are still leaving Tennyson open to External Pathogenic Damp-Cold, then of course I would want to Resolve Damp and Expel Cold to alleviate his more acute symptoms.

Spleen Qi Xu and Yang deficiency is brought about by the breakdown of the Spleen’s function of transformation and transportation. “The Spleen failing to transport Food Qi (Gu Qi) to the four limbs causes them to be weak” (CICM, 2019, p95). The Spleen produces Gu Qi, and Gu Qi is the origin of Blood, so Spleen Qi Xu may also lead to Liver Blood Xu (Maciocia, 2012).

If chronic diarrhoea persists with abdominal distension as opposed to acute diarrhoea, then I would want to Tonify his Spleen Qi and Resolve Dampness. If there was no slipperiness on the pulses and they were just deep, deficient, and slow, plus no white coating on the tongue with Tennyson still feeling cold with sudden chronic diarrhoea,then I would want to Tonify and Warm Spleen and Kidney Yang as well as Strengthen Fire of the Gate of Life.

Unexpected Patterns identified on this Chinese Medicine assignmentresearch
I would not expect to treat directlyLiver Blood Xu as treating his Lung Qi, Spleen Qi, Spleen and Kidney Yang deficiencies, will greatly help with blood production along with improving his diet. I would expect that the numb feeling in his fingers and toes will improve. If it doesn’t improve, thenthat suggests that it’s due to diabetic peripheral neuropathycomplications and that blood flow has been impaired and needs to be treated directly.

Dealing with the mixed condition
Sp 3 Supreme White, Earth pointis a very important point for bringing vitality and stability to Spleen. The Chinese Medicine assignmentassociated this point with the Lungs through the mother-child connection as Earth is the mother of Metal Element. When combined with St 36 horary pointor St 42-yuan source point (Hicks, Hicks, Mole, 2011).

Frequency of treatments and in that circumstances that affects the frequency variation and signs to look after for assessing progress in treatment, including changes to tongue and pulse
The frequency of treatments would be weekly for the next 4 weeks to begin with, and then depending on progress, fortnightly and then monthly. Ifbowels became more regular and the patient started to feel more positive about himself and his life, along with a corresponding harmony and strength in his pulses, then I would feel that treatment was going well. His tongue should appear less swollen, less pale with a normal thin coating. Hopefully, with his strengthened CF and Wei Qi, improved diet and general lifestyle change, the patient would not be invaded so regularly by External Pathogenic factors. As a practitioner, I would have to keep alert to any changes in his pulses, tongue, and general demeanour.

Symptoms and patterns that may arise in future if Tennyson does not continue with acupuncture treatment In the future, if Tennyson does not continue with acupuncture treatment, he may continue to suffer from diarrhoea, dehydration, and invading pathogens. “Some common side-effects of diabetes include kidney disease, eye problems and nerve damage” (Hicks, 2015, p273). As he gets more Blood deficient, he may get problems with Blood Stagnation leading to poor circulation, stroke and heart attack (Stephenson, 2016).

Spleen Qi deficiency is always an underlying predisposing imbalance in adult-onset diabetes(Stephenson, 2016). Untreated acute diabetes can, can be summarised in terms of Yin Deficiency with Accumulation of Heat or Fire.

Question 3: Chinese Medicine assignmentTreatment principles and two treatment plans
3a) A simplified and prioritised list of treatment principles
Following is a list of simplified and a prioritised principles of treatment that could be applied in Tennyson’s case in order to treat his condition efficiently.
• Resolve Damp and Expel Cold
• Treat Metal CF. Tonify Lung Qi and Warm Lung Yang
• Tonify Spleen Qi to Resolve Dampness
• Tonify and Warm Spleen and Kidney Yang
• Strengthen Fire of the Gate of Life
• Nourish Liver Blood

Hopefully, I would not have to treat using all the treatment principles above because by treating CF and by clearing his External Pathogenic Damp-Cold when necessary, many of the other syndromes will resolve as a knock-on effect, as long as Tennyson also follows his dietary and lifestyle advice.

3b) Designing two treatments to illustrate the plan of treatment to take Tennyson’s treatment further
Treatment 1: Treat Metal CF
Assuming this is the 7th or 8th treatment and many of his signs and symptoms have improved, and he is feeling better in himself then I would continue treating CF only for a while. I would focus on enhancing the patients’constitutional healthbybalancing his Mind, Body and Spirit.

Lu 9, Great Abyss: Tonification point, Yuan-Source point, Earth point, Shu-Stream point, Hui point for Arteries and Blood Vessels. Tonifies all Lung Patterns including Lung Qi and Lung Yin. Regulates Lung Qi. Promotes Circulation of Blood and influences the pulse (CICM, 2018). Tonification with Moxa. This Chinese Medicine assignmentpoint will help to restore order and trust in life as well as revive his deep, weak pulses.
LI18 Support the Prominence, Window of the Sky: This point allows clarity and movement into the situation and helps balance to Body, Mind and Spirit. It can support and strengthen one’s ability to let go of difficult or painfulcircumstances and allow new vistas and perspectives to unfold. When combined with LI4, these effects are further enhanced (Acupuncture Point Compendium, 2014)
LI 4, Joining Valley: Yuan-Source point, Entry point. Tonifies Qi and Consolidates the Exterior. Harmonises Ascending and Descending (CICM, 2018). Tonification.
It is good for mind, body and spirit, for relieving anxiety as well as for strengthening Wei Qi (Hatton, 2014).
BL13 Lung Back Shu: Stimulate Descending and Dispersing function, Regulate Lung Qi. Regulate Ying and Wei Qi. Tonify Lung. Its main use is for all Lung Syndromes External and Internal(Acupuncture Point Compendium, 2014). BL 42 Door of Po: It will enable to let go of grief and sadness that depleted spirit. Combined together with BL13will bring stronger and deeper effects (Hicks, 2011).

I would expect the patient to feel great after this treatment. He should feel warmer in temperature with more energy. I would hope that all his pulses would harmonise and feel stronger by the end of the treatment. The Windows of Sky pointsare very powerful and always added in situations where the patient is still showing signs of a depressed spirit and not enjoying his better health.They would increase vitality and spontaneity which make it possible to initiate change. (Hicks, Hicks,Mole 2011).

Changes that will be considered well for a result of this treatment
I would be looking for changes in patient spirit. If a patient’s spirit doesn’t improve it means that the body is still suffering more than the spirit and I would need to concentrate on treating CF to nourish the root. I will focus on treating the Lungs to treat thirst, the Spleen to treat hunger, and the Kidneys to treat frequent urination and low back pain.

Treatment 2: Treat acute main complaint
Over the last 24 hours,the patient has had watery, but not smelly, stools with abdominal pain that eases with the use of a hot water bottle, but does not completely go. His stomach is “rumbly” and he feels generally out of sorts, with aching joints, a slight headache and congested sinuses. His bowels are completely out of control with undigested food in the stools with a sudden, cold feeling in his abdomen just beforehand and accompanying abdominal pain. Even needle technique can be used because the patients’ overall picture is too deficient for the use of Reduction technique. Using Moxa would help to Dispel the Cold and it would also have an anti-pathogenic effect. Hatton says that the use of Front Mu points such as St 25, are particularly indicated in acute excess situations (Hatton 2014) so I think that these points would be particularly good for patients’ acute diarrhoea and pain. Hatton (2014) says that Stomach 36 is also the Command point of the Stomach, and it can be used to relieve masses in the abdomen, pain, and distension.

• St 25, Heavenly Pivot: Front Mu point of LI to Promote functions of the Large Intestine. Relieve Retention of Food. Regulate Qi in the Lower Jiao (CICM, 2018). Even with Moxa.

• St 36, Leg 3 Miles: He-Sea Point, Earth Point, Point of Sea of Food. Benefits the Stomach and Spleen. Dispels Cold. Regulates Ying and Wei Qi. Regulates the Intestines. Raises Yang. Clears Damp. Resolves Oedema (CICM, 2018). Even with Moxa for Anti-Pathogenic effect.

I would then continue the treatment using Tonification with Moxa on Ren4 and indirect Moxa on Ren8. Both points should help reduce the amount of undigested food in his stools by warming and stabilizing his Spleen and Kidney Yang. These points should also calm and strengthen his Spirit.Ren 8 would help with chronic diarrhoea as it clearly comes from a place of deficiency as well as excess and cold in the system, particularly lower and middle Jiao, and the extremities.

• Ren 4, Gate to the Yuan Qi: Front Mu point of the Small Intestine, Meeting point of Ren, Spleen, Liver and Kidney. Tonifies Qi, Blood and Yin. Calms the Spirit and Rescues Yang. StrengthensYang Qi when used with Moxa.
• Ren 8, Shen Palace Gate: To Warm and Stabilise Yang. Strengthen the Spleen. Strengthen the Spirit. Treats diarrhoea from Spleen Yang deficiency where there is cold and inability to raise Qi;Cold in the system, particularly lower and middle Jiao, and the extremities.

Question 4:Clinical complexity identified on this Chinese Medicine assignment
The patient is also receiving conventional medical care from his GP and the diabetic nurse at his GP practice. He has received some general education and lifestyle advice concerning Type-2 DiabetesMellitus. His is GP has prescribed Metformin 500mg, to be taken twice daily with his breakfast and evening meal.

I would talk to him about his current high intake of sweet, raw, cold and damp-forming foodsand the effects on his condition. His tendency to snack on bananas, tropical fruit and salad, as well as drinking two litres of pineapple juice, tropical fruit smoothies, large amounts of cold water along with four to five mugs of milky coffee every day is surely going to make him colder, damper and more susceptible to repeated invasions of External Pathogenic Damp-Cold, given his constitutionally weak Wei

Qi.
I would also recommend that he have a look at Daverick Leggett’s book, “Helping Ourselves” (1995). The bookis free to download and suited to practitioners, students and clients of Chinese medicine. It contains simple one page explanations of each basic diagnostic pattern and the foods that will assist its healing. I would talk aboutstrengthening his Spleen and helping quell his troublesome diarrhoea and that he will need to include warmer, more Blood nourishing foods in his diet. For instance, salads, are too cold and damp for the Spleen to perform at its best, He could swap these for warm nourishing soups containing, for example, beetroot.

Leggett (1995) has also published a poster called “A guide to The Energetics of Food based on the traditions of Chinese Medicine”. I would print out and give it to him. The poster explains that the temperature of his food will have an effect on his metabolism after initial digestion. I would explain that anyone with cold constitutions like his, need to eat more warming foods. He could therefore reduce his intake of foods shaded in blue, such as yoghurt, banana, lettuce, mango and melon, and make sure that he eats more heated food instead of cold salads. Leggett (1995, p1) says that in “acute cases of pathogenic invasion warm or hot foods are combined with stronger pungent flavours to drive out Cold. Effective foods include Anchovy, Basil, Bay, Black Pepper, Cayenne, Cherry, Chestnut, Chicken, Coriander Seed, Dill Seed, Fennel Seed, Garlic, Ginger, Kohlrabi, Lamb Kidney, Leek, Mussel, Mustard Leaf, Mutton, Nutmeg, Onion, Peach, Pine Kernel, Rosemary, Scallion, Shrimp, Squash, Sweet Potato, Sweet Rice, Trout, Turnip, Vinegar, Walnut” and Wine. As Tennyson is a Metal CF some of the more pungent flavoured foods could be particularly good for Tennyson as they could scatter the invading Cold by moving Qi (Hicks, Hicks & Mole, 2011).

As patient also displays Dampness, partly because of his sensitivity to the damp climate he lives in, over-nutrition and lack of exercise he could also reduce or avoid dairy products, roasted peanuts, rich meats, concentrated fruit juices, wheat, sugar, sweeteners and saturated fat. As he has now Type 2 Diabetes, then cutting down on his pineapple juice and smoothies would be a very important message to get across. He could have black coffee, replace his wheat-based cereal with warm porridge and use almond milk instead of cow’s milk.

On this Chinese Medicine assignmentI would explain Dr Jason Fung’s book, “The Diabetes Code” (2018), even though doctors prescribe Metformin to lower blood glucose levels, this drug does not rid the body of excess glucose, and this ends up in other organs such as the eyes, the heart, the kidneys and nerves where the sugar creates other problems. This is very important information to understand for anyone including me, as it explains how to “prevent and reverse Type 2 Diabetes naturally”. Diabetes UK (2019) have information about several different weight-loss diets on their website including a low fat healthy balanced diet, a low-carb diet, a low-calorie diet, a Mediterranean diet, a low glycaemic index (GI) diet, commercial weight-loss programmes and it even mentions intermittent fasting, like the 5:2 diet, which may be in conflict with Chinese Medicine advice to eat regularly.

I would ask him to read the book, “Healing Your Emotions” (Hicks & Hicks, 1999) to understand the mind-body connection and the prevention of disease. I would recommend that he try out the Qigong exercises for moving energy through the chest and for breathing fully. If this helps with his breathing, then maybe he might consider attending a local Qigong class. I would explain that regular moderate exercise reduces the risk of circulation problems and that, in fact, “eating regularly, sleeping regular hours and getting regular exercise have all been found to increase the sugar control of a diabetic and thus improve health” (Hicks, 2015, p274).

Moderate intensity means that he should breathe more heavily but should still be able to speak. If he does not fancy Qigong, then maybe he could try taking a brisk walk, going for a bike ride or gardening. Diabetes UK (2019) also recommends swimming but, for Tennyson, with his recurrent problems with Damp-Cold and his fragile lungs, I would not recommend this exercise for him at this stage.

Diabetes UK (2019) and the NHS (2019) food guidance for diabetes recommend eating healthy, balanced and regular meals with more filling breakfasts which, on the surface, does not seem to conflict with Chinese Medicine advice. However, Chinese Medicine assignmentreviews state they also recommend a few Damp and Cold forming foods such as wholegrain wheat bread with peanut butter, wheat pasta, bananas, milk, cold salads or sandwiches for lunch, raw vegetable crudities and raw fruit. In their book “Chinese Dietary Wisdom”, Blyth and Lampert (2015), say that if you are experiencing diarrhoea, then you must avoid all raw foods. If you are going to eat fruit, then cook it! Ice cream, yoghurt, bananas and cucumber are Cold in nature so must be avoided too.

Tennyson must take heed!
The benefits I may hope to bring to both him and his symptoms with my approach to his care and my professional role as Tennyson’s acupuncturist
The benefits that I hope to bring to his health with my approach to his care will hopefully mean that he will no longer experience any, or as many, of the following ‘Red Flag’ symptoms for diabetes as listed by Stephenson (2013). I will make sure that Tennyson is aware of the following:

• If the levels of glucose in Tennyson’s blood became too high, this would be considered to be uncontrolled diabetes. Confusion and coma can result due to hyperglycaemia. These are urgent red flags and medical help should be summoned immediately. If the patient is losing consciousness they must be “kept in a safe place in the recovery position until help arrives” (Stephenson, 2013, p73).
• Confusion and coma can also stem from hypoglycaemia, which could be due to the effects of insulin in some patients, but in Tennyson’s case it could be a reaction to him taking too much ant diabetic medication, i.e. Metformin. Taking glucose immediately will help prevent him from losing consciousness.
• Potentially poorly controlled Type 2 diabetes in Tennyson’s case, or Type 1 diabetes can result in thirst, excessive urination and progressive weight loss. Stephenson (2013, p73) says that, “Thirst and excessive urination are due to the osmotic effect of glucose in the urine. Weight loss occurs because the tissues are unable to utilise the glucose in the situation where there is a lack of insulin.” As this also can lead to coma due to rising lactic acid, I would point out to Tennyson how important it is for him to follow my Chinese Medicine dietary advice.
• This appears to be a less urgent red flag but still a high priority. Tennyson will certainly have noticed these symptoms. Untreated Type 2 diabetes develops over the course of weeks to months as the symptoms of feeling unwell with thirst, along with an increased need to urinate, become gradually more noticeable. These “sustained levels of hyperglycaemia put the patient at increased risk of heart disease, kidney disease, vascular disease and chronic infections” (Stephenson, 2013, p74).
• Another indication of Type 2 diabetes is the increased likelihood of urinary infection, such as cystitis, and a tendency to skin infections such as thrush, boils and, in Tennyson’s case, impetigo. This may be the reason that Tennyson visited his GP and was, subsequently tested for diabetes.
• Lastly, Patient had a cut on his foot, which, ‘took longer than he would have expected to heal’. This is due to skin becoming vulnerable to damage because of poor circulation to large and small blood vessels and impaired nourishment of the skin resulting in frequent skin infection. Hence, importance of Diet and moderate exercise. “Any poorly healing wounds in diabetes merit high priority referral for consideration of treatment” (Stephenson, 2013, p74). In this Chinese Medicine assignment“poor healing with a tendency to infections might relate to Blood and Qi Deficiency with Damp or Damp Heat” (Stephenson, 2015, p406), possibly leading to Tennyson’s impetigo.

Gascoigne (2001, p298) mentions that the long-term consequences of having diabetes mellitus include the following:
• “Atherosclerosis: Cold limbs, pain in calves on walking, absent peripheral pulses.
• Diabetic neuropathy: Tingling and numbness especially in extremities. Again, due to damage to small blood vessels that supply the nervous system. Single nerves may suddenly die causing weakness of a muscle group in a limb or double vision. The autonomic nerves can also be affected, leading to problems such as diarrhoea, erectile dysfunction, dizziness on standing and difficulty in passing urine (Stephenson, 2013, p450).
• Retinal damage: Impaired vision, in some cases, blindness.
• Glomerulonephritis: Oedema, loin pain, haematuria.”

I would like to prevent the chances of Tennyson suffering the above symptoms related to these potential long-term complications of diabetes. As his acupuncturist, I would see my professional role as someone who would greatly encourage him to take an interest in his own health and his own potential recovery. I would support, warm and raise his Mind, Body and Spirit with the use of acupuncture points with moxa. I would look forward to seeing him, a Metal CF, more comfortable and relaxed in his own skin. I would resolve and clear his more acute bowel symptoms whenever they reappear with the use of even technique with moxa, and then continue to discuss how he could take steps to stop this from happening.

It would be great if we could find a way for Tennyson to reduce or even stop his need to take Metformin by preventing and reversing his Type 2 Diabetes naturally.
PubMed article states that “Conventional pharmaceutical therapies for Type 2Diabetes Mellitus are not efficacious enough to maintain satisfactory blood glucose levels for all patients, and even patients who maintain stable blood glucose levels may still suffer from secondary Type 2 Diabetes symptoms as well as from the side effects of their medications. Acupuncture and Chinese Herbal medicine have demonstrated promising results in Type 2 Diabetes Mellitus clinical studies without causing the types of side effects associated with standard pharmaceutical treatments (Xiao, Eric & Luo, and Luguang. 2017).” To conclude this Chinese Medicine assignment, I would love to see positive cooperation in the treatment of diabetes type 2 between GP and Acupuncturists in near future.

Reference list
Blyth, D and Lampert, G., 2015.Chinese Dietary Wisdom: Eating for Health and Wellbeing, Reading: Nutshell Press. Chinese Medicine assignment
BNF, 2016.BNF 72, London: BMJ Group and Pharmaceutical Pres
CICM, 2017.Theory Handouts, Reading: CICM
CICM, 2018.Points Guide, Reading: CICM
Diabetes UK, 2019. Know diabetes, fight diabetes [online], Available from: Living with diabetes | How to manage diabetes | Diabetes UK[accessed 31st Jan 2022]
Dugdale D, MD,Epstein R, MD and Pantilat SZ, MD :Time and the Patient–Physician Relationship.Journal of General Internal Medicine. 1999 Jan; 14 (Suppl 1): S34–S40
Fung, Dr J, 2018. The Diabetes Code: Prevent and Reverse Type 2 Diabetes Naturally, Canada: Greystone Books Ltd Gascoigne, Dr S, 2001. The Clinical Medicine Guide: A Holistic Perspective, Abergavenny: Jigme Press Hatton, C-L., 2014. Acupuncture Point Compendium: Third Edition, College of Traditional Acupuncture Hicks, A., 2015.88 Chinese Medicine Secrets: How the wisdom of China can help you stay healthy and live longer, London: Robinson Hicks, A and Hicks J., 1999. Healing your Emotions, London: Thorsons Hicks, A, Hicks, J, and Mole, P., 2011. Five Element Constitutional Acupuncture, Second Edition, Edinburgh: Churchill Livingstone

Leggett, D., 1995.A Guide to The Energetics of Food based on the Traditions of Chinese Medicine, Totnes: Meridian Press
Leggett, D., 1995.Helping Ourselves: A Guide to Traditional Chinese Food Energetics, Totnes: Meridian Press Maciocia, G., 2012. ‘On Blood Deficiency’:The European Journal of Oriental Medicine [Online], Available from: EJOM_Blood_Deficiency.pdf (giovanni-maciocia.com)[accessed 31 January 2022].
NHS, 2019.Type 2 diabetes – Food and keeping active [Online], Available from:nhs.uk/conditions/type-2-diabetes/food-and-keeping-active/. [accessed 31 January 2022]
Stephenson, C., 2013.The Complementary Therapist’s Guide to Red Flags and Referrals, London: Elsevier Ltd.
Stephenson, C., 2016. The Complementary Therapist’s Guide to Conventional Medicine, London and Philadelphia: Singing Dragon Xiao, Eric and Luo, Luguang, 2017. Alternative Therapies for Diabetes: A Comparison of Western and Traditional Chinese Medicine (TCM) Approaches. Current diabetes reviews. 13. 10.2174/1573399813666170519103230. Online available fromAlternative Therapies for Diabetes: A Comparison of Western and Traditional Chinese Medicine (TCM) Approaches - PubMed (nih.gov)[accessed 5thFebruary 2022]

Appendix
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