Use of complementary and alternative medicine among people living with diabetes: literature review

Use of complementary and alternative medicine among people living

with diabetes: literature review

Hsiao-yun Chang, Marianne Wallis & Evelin Tiralongo

Accepted for publication 1 February 2007

Hsiao-yun Chang BN MN RN

PhD Candidate

School of Nursing and Midwifery, Griffith

University, Gold Coast, Queensland,

Australia

Marianne Wallis BSc PhD RN

Professor of Clinical Nursing Research

Griffith University Research Centre for

Clinical Practice Innovation and Gold Coast

Health Service District, Queensland,

Australia

Evelin Tiralongo BPharmSc PhD

Lecturer

School of Pharmacy, Griffith University Gold

Coast, Queensland, Australia

Correspondence to Hsiao-yun Chang:

e-mail: [email protected]

CHANG H.-Y. , WALLIS M. & TIRALONGO E (2007)CHANG H.-Y. , WALLIS M. & TIRALONGO E (2007) Use of complementary and

alternative medicine among people living with diabetes: literature review. Journal of

Advanced Nursing 58(4), 307–319

doi: 10.1111/j.1365-2648.2007.04291.x

AbstractTitle. Use of complementary and alternative medicine among people living with

diabetes: literature review

Aim. This paper is a report of a literature review to explore the prevalence of

complementary and alternative medicine use amongst people with diabetes to in-

form nursing practice, education and research.

Background. Diabetes mellitus affects the entirety of a person’s being and increas-

ingly people use complementary and alternative medicine in conjunction with other

medical treatments and lifestyle modifications to manage their condition and

improve well-being.

Methods. The CINAHL, Medline, ProQuest nursing journals and Psych INFO

databases were searched for the period 1990–2006 using identified keywords.

Results. A total of 18 studies from nine countries were found. The results suggest

that the prevalence of complementary and alternative medicine use among people

with diabetes ranges from 17% to 72Æ8%. The most widely used therapies among

diabetic populations are nutritional supplements, herbal medicines, nutritional

advice, spiritual healing and relaxation techniques. The characteristics which

influence complementary and alternative medicine use are age, duration of diabetes,

degree of complications and self-monitoring of blood glucose.

Conclusion. Although inconsistency in the definition of complementary and alter-

native medicine and varying research designs make estimation of usage prevalence

difficult, evidence suggests that a high proportion of people with diabetes use these

therapies concurrently with conventional healthcare services. Healthcare profes-

sionals need to be aware of this issue and may need to incorporate complementary

and alternative medicine information into patient assessment and intervention.

Keywords: alternative medicine, complementary medicine, diabetes mellitus,

literature review, nursing, prevalence

Introduction

Interest in and use of complementary and alternative medicine

(CAM) has recently expanded in many countries around the

world. Population-based studies in countries in the developed

world, such as Australia, Scotland, UK, Taiwan, Singapore

and the United States of America (USA), report that one-half

to two-thirds of adults use CAM (Emslie et al. 1996,

REVIEW PAPERJAN

� 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd 307

MacLennan et al. 2002, Lew-Ting 2003, Lim et al. 2005,

Tindle et al. 2005). This significant CAM usage in the general

population can be expected to lead to a demand for informa-

tion on CAM usage by the clients of health professionals.

The presence of chronic, debilitating or painful illness has

consistently been found to be a reason people seek out CAM

(Eisenberg et al. 1998). Diabetes mellitus (DM) is one such

disease which is highly prevalent worldwide. The mortality

associated with diabetes is significant, and primarily arises

from complications of long-standing hyperglycaemia.

Around 3Æ2 million deaths every year worldwide are attrib-

utable to complications of diabetes, which equates to six

deaths every minute (World Health Organization 2004).

Conventional medicine for diabetes has been geared toward

regulating blood glucose with a combination of dietary

modification, insulin and/or oral agents, maintaining ideal

body weight, exercising regularly and self-monitoring blood

sugar. Good glucose control can, however, be difficult for

many people with diabetes, because these conventional

treatment plans require changes to behaviour and lifestyle

(Dunning 2003). Due to the chronic course of the disease, the

debilitation of complications and threat of death, as well as

the complexities of treatment plans, people with diabetes

often work proactively to manage their condition, optimize

their health and alleviate complications through the use of

CAM (Yeh et al. 2002, Dunning 2003, Bell et al. 2006).

Complementary and alternative medicine refers to prac-

tices, approaches, knowledge and beliefs incorporating plant,

animal and mineral-based medicines, spiritual therapies,

manual techniques and exercises (World Health Organization

2003). A variety of definitions and descriptions are used to

explain CAM. The most broadly used functional definition of

CAM has been developed by the National Centre for

Complementary and Alternative Medicine (NCCAM) in the

USA. This definition states that ‘CAM is a group of diverse

medical and healthcare systems, practices and products that

are not presently considered to be part of orthodox medicine’

(NCCAM 2002, p. 1). CAM is a categorical term that

encompasses a broad spectrum of medicines, therapies and

practices. The NCCAM categorized CAM into five major

domains:

(1) Alternative medical systems: these are built upon com-

plete systems of theory and practice, such as homeopathic

medicine and traditional Chinese medicine.

(2) Mind–body interventions: these use a variety of tech-

niques designed to enhance the mind’s ability, such as

meditation, prayer and art therapies.

(3) Biologically based therapies: these use substances found

in nature, such as dietary supplements, herbal products

and botanical products.

(4) Manipulative and body-based methods: these are based

on the movement of one or more body parts, such as

chiropractic, osteopathic and massage.

(5) Energy therapies: these involve the use of energy fields

that are believed to surround and penetrate the human

body, such as biofield therapies (Gi Gong and Thera-

peutic Touch); and bioelectromagnetic-based therapies

(pulse fields and magnetic fields).

Despite the diverse ways in which these systems and

therapies have developed, they share common themes, such

as the use of complex interventions; individual diagnosis;

belief in the healing power of nature; union of mind, body

and spirit; and more holistic and integrative approaches to

individualized treatment plans. Several comprehensive

reviews have been written on the evidence that CAM

therapies can be beneficial for the management of diabetes

(Goguen & Leiter 2001, Shane-McWhorter 2001, Dey et al.

2002, Liu et al. 2002, Yeh et al. 2003). For example, a

number of herbal medicines and nutritional supplements have

been shown to decrease blood glucose level through various

mechanisms, and if used correctly, these effects can help

people with diabetes to manage their disease and to improve

their quality of life (see Table 1). However, while evidence is

mounting in support of the use of various CAMs to treat

diabetes and its complications, it is unclear how many people

with diabetes use CAM and whether they use the CAMs that

are beneficial for diabetes management.

Aim

The aim of the review was to explore the prevalence of CAM

use amongst diabetic populations in order to inform nursing

practice, education and research.

Search methods

Databases and keywords

The following databases were searched for the period 1990

to October 2006: CINAHL, Medline, ProQuest nursing

journals and Psych INFO. The keywords used were com-

plementary and alternative medicine, complementary medi-

cine, complementary therapy and alternative medicine (and

related terms such as traditional medicine, folk medicine

and unconventional/non-conventional medicine), prevalence

and DM. Some papers were found through tracking citations

from other publications. Inclusion criteria were prevalence

studies of CAM use by people with diabetes and other

research reports of studies exploring CAM use by people

with diabetes. Exclusion criteria were: publication in a

H.-Y. Chang et al.

308 � 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd

language other than English; not available by inter-library

loan service in Australia; and publication dates before 1990

as this was when the increasing use of CAM began to be

reported.

Review limitations

This review included research-based studies focusing on

CAM use among people with diabetes. As this was not a

systematic review of efficacy, expert judgement rather a

formal quality appraisal was used to determine which studies

were included. Some studies which demonstrated design,

selection and measurement bias were included because they

provided useful insights into either the problems in definition

of terms or because they included information about disclo-

sure to healthcare professionals.

Results

The search produced 232 abstracts. This number was further

reduced by selecting research-based papers, specifically those

studies related to the prevalence of CAM use and those

related to the types of CAM commonly used by people with

diabetes. This resulted in 18 papers being selected for

inclusion in the review. Thirteen reported quantitative studies

that related to prevalence of CAM use and type of CAM used

by people with diabetes. Five reported qualitative studies

related to the type of CAM used by people with diabetes. The

Table 1 Overview of herbal medicine and nutritional supplements used in the treatment of diabetes

Herbal medicines Effects

Potential interactions and

contraindications References

Bitter melon

(Momordica charantia)

Hypoglycaemic activity Hypoglycaemic agents

Pregnancy

Basch et al. (2003)

Fenugreek

(Trigonella foenum graecum)

Hypoglycaemic activity

Lipid-lowering effects

Increased HDL cholesterol

Hypoglycaemic agents

Pregnancy

Anticoagulant drugs.

MAO inhibitors

Yeh et al. (2003)

Ginseng (Panax ginseng) Hypoglycaemic activity

Improved psycho-physiological

performance

Immune stimulant effects

Hypoglycaemic agents

Corticosteroids

Oral contraceptives

Anticoagulant drugs

Digoxin

MAO inhibitors and tricyclic

antidepressants

Diuretics

Sievenpiper et al. (2004)

Ginkgo (Ginkgo biloba) Antioxidant, Neuroprotective

Beneficial in cerebrovascular

insufficiency and peripheral

vascular disease

Anticoagulant drugs

SSRI

MAO inhibitors

Herbs: ginger, garlic and feverfew

Shane-McWhorter (2001)

Supplements

Chromium Increased insulin sensitivity


N/A Guerrero-Romero and

Rodriguez-Moran (2005)

Fish oil Triglyceride-lowering effects

Anti-inflammatory

Anti-platelet

Hypotensive

Pregnant or breastfeeding

Anticoagulant drugs

Anti-hypertension drugs

Farmer et al. (2001),

Pittler and Ernst (2005)

Magnesium Essential in glucose metabolism

Prevent diabetic complications

Antibiotics

Drugs to prevent osteoporosis

Calcium channel blockers

Muscle relaxants

Diuretics

Guerrero-Romero and

Rodriguez-Moran (2005)

Zinc Metalloenzyme activitor

Immune function

Improved insulin levels


Improved weight loss

Reduce absorption folic acid,

tetracyclines, copper

Reduce the effect of therapies that rely on

dopamine receptor antagonists

Vitamin A

Franz et al. (2002)

JAN: REVIEW PAPER Use of complementary and alternative medicine people with diabetes


remaining papers were either not research-based studies or

not related to the purpose of this literature review. All the

included studies were reviewed and compared, then sum-

marized in a matrix form, in terms of the aims of the review.

The key data from the 18 publications covered in this

review are summarized in Tables 2 and 3. Most of the studies

were published between 2000 and 2006 with only one study

published during the 1990s. Publications were based on

studies conducted in nine countries. The majority of papers

were derived from the USA (nine studies) and Australia (two

studies). Most of the studies were conducted in developed

countries with respondents recruited from conventional

hospitals. Unfortunately, data from Europe were limited,

because there were either none reported in English or no

studies conducted. Although this is a limitation, the present

review summarizes the available data on the prevalence of

CAM use among people with diabetes worldwide.

Challenges in interpreting the published literature

The papers reviewed report a high level of CAM use in people

with diabetes attending conventional healthcare services in

different countries and regions. The comparison of CAM use

prevalence data between these studies is difficult, however,

because these studies differ markedly in their definitions of

CAM, research design, methods of data collection, time-

frames and response rates.

Defining the term CAM is not an easy task. Murphy et al.

(2003) searched biomedical databases on CAM to estimate

the degree to which the literature displays the use of

controlled vocabulary among authors, indexers, and inves-

tigators, and concluded that validity of the definition of

CAM was the most difficult search concept, largely due to

inconsistent use of terminology between studies. As Table 2

demonstrates, the reviewed research studies provided limited

information about the instruments used. Each study had its

own operational definition of CAM and there were differ-

ences between the specific types of therapy included as

CAM, which therapies were classified into which subcate-

gory and how many CAMs were investigated. For example,

the studies of Ryan et al. (2001), Yeh et al. (2002), Garrow

and Egede (2006) and Bell et al. (2006) used different

criteria to determine whether vitamins or mineral supple-

mentation were defined as a form of CAM and thus,

included in the survey. If some studies had included all types

of vitamins not just mega-vitamins, the reported CAM use

could be much higher than the original data. In comparison

with these studies, electrotherapy, exercise, special diet

control and psychotherapy seldom came under the umbrella

of CAM.

The second problem regarding the operational definition of

CAM is the manner in which different researchers categorize

CAM. Rather than using the NCCAM’s domains, some

researchers use other conceptual models; for example, in the

Lee et al. (2004) study, biologically based therapies were

further categorized in terms of the origin of the CAM

product, such as plant-derived, animal materials and miscel-

laneous.

The third problem that arose when attempting to compare

the selection of CAM therapies used in studies, was the lack

of consistency with which CAMs were included in the

investigation. For example, some studies focus only on the

usage of the ‘biologically based therapies’ such as vitamins,

nutritional supplements and herbal medicine, whereas a

number of surveys included the whole spectrum of CAM

therapies. Only one study (Lind et al. 2006) reported

consultation with CAM practitioners by people with diabe-

tes. All these differences and inconsistencies can be seen in the

Table 2, under ‘research question’ and ‘popular therapies

list’. Because of a lack of consistency in categorization of

CAM therapies and a lack of consensus about which type and

how many therapies should be examined, it is difficult to

make an accurate evaluation of the frequency with which

CAM therapies are used.

A variety of research designs have been used in an attempt

to assess CAM use among people with diabetes. When

reviewing the literature on the prevalence of CAM use, a

number of important caveats have to be considered, such as

the fact that each survey covers a slightly different timeframe,

selection criteria vary and the methods of recruitment vary

(Ernst 1999). Some surveys were aimed at determining

lifetime prevalence of CAM use, while others used 1 year

or current use data. These differences may be seen in the

column of ‘timeframe’ in Table 2. Some researchers, such as

Leese et al. (1997), Al-Saeedi et al. (2003), Argaez-Lopez

et al. (2003) and Ryan et al. (2001) did not mention the

timeframe at all. In the studies that investigated lifetime

prevalence of CAM use there was limited reporting of the

measures taken to minimize recall bias.

Another issue of considerable importance in comparing

and contrasting previous studies is the difference in meth-

odological approaches undertaken by researchers. To enable

high response rates, survey questions are necessarily short

and uncomplicated (Harris & Rees 2000). Self-reported

questionnaires and telephone interviews, in particular, are

dependent for accuracy, upon respondents’ knowledge of

CAM therapies, and/or their willingness to report that use. As

a consequence, the quality of data related to the prevalence of

CAM use may be influenced by these factors. Additionally,

most studies had selection biases as a result of high

H.-Y. Chang et al.


Table

2Q

uan

tita

tive

rese

arc

hre

port

sre

late

dto

com

ple

men

tary

and

alt

ernati

ve

med

icin

e(C

AM

)th

erapie

suse

dby

peo

ple

wit

hdia

bet

esm

elli

tus

(DM

)

Auth

or

Countr

yn

(RR

)D

esig

nsa

mpli

ng

Res

earc

hques

tion

Tim

efra

me

Use

rate

Popula

rth

erapie

slist

(%)

Lee

seet

al.

(1997),

UK

246

DM

(75%

)

Conven

ience

sam

ple

wit

hper

sonal

inte

rvie

w

Pati

ents

att

endin

gth

e

dia

bet

escl

inic

ass

esse

d

the

uti

liza

tion

of

CA

M

NM

17%

Acu

punct

ure

(n¼

18)

Hom

eopath

y(n¼

11)

Her

bal

ther

apy

(n¼

7)

Refl

exolo

gy(n¼

4)

Aro

mat

her

apy

(n¼

4)

Hypnoth

erap

y

(n¼

3)

Cel

luar

nutr

itio

n

(n¼

2)

Chir

opra

ctor

(n¼

2)

Oth

ers

(n¼

5)

Ryan

etal

.(2

001),

Canada

703

DM¼

502

Non-D

M¼

201

(NM

)

Non-r

andom

sam

ple

52%

per

sonal

inte

rvie

w

48%

tele

phone

inte

rvie

w

What

kin

dof

med

icati

on

pre

sentl

yin

use

of

over

-the-

counte

r

supple

men

ts(O

TC

S)and

anoth

erm

edic

ati

on

(AM

)?

NM

AM

31%

OT

CS

44%

OT

Csu

pple

men

ts

Mult

ivit

am

ins

(27Æ5

)

Vit

am

inE

(18Æ9

)

Vit

am

inC

(18Æ7

)

Calc

ium

(16Æ0

)

Asp

irin

(13Æ9

)

Vit

am

inB

Com

ple

x

(6Æ5

)

Alt

ernati

ve

med

icin

es

Gar

lic

(11Æ6

)

Ech

inace

a(8

Æ9)

Her

bal

mix

ture

s

(8Æ5

)

Glu

cosa

min

e(5

Æ8)

Chro

miu

m(5

Æ8)

Gin

kgo

bil

oba

(4Æ9

)

Eged

eet

al.

(2002),

USA

21,5

71

DM¼

825

(77Æ7

%)

Nati

onally

repre

senta

tive

sam

ple

wit

hhouse

hold

inte

rvie

w

Have

you

seen

an

alt

ernati

ve

hea

lthca

re

pro

vid

ersu

chas

those

list

ed?

12

Ms

NM

Fiv

eco

mm

on

type

of

CA

M

Nutr

itio

nal

advi

ce

(n¼

37)

Her

bal

rem

edie

s

(n¼

20)

Spir

itual

hea

ling

(n¼

21)

Mass

age

ther

apy

(n¼

19)

Med

iati

on

train

ing

(n¼

14)

Pro

vid

erof

CA

M

Cle

rgy/s

pir

itualist

(n¼

18)

Mass

age

ther

apis

t

(n¼

16)

Nurs

e(n¼

13)

Acu

punct

uri

st

(n¼

9)

Yeh

etal

.(2

002),

USA

2055

DM¼

96

(NM

)

Nati

onally

repre

senta

tive

sam

ple

wit

hte

lephone

inte

rvie

w

Have

you

ever

use

dany

of

the

follow

ing

16

ther

apie

s?

Ifso

,have

you

done

so

wit

hin

the

last

12

month

s?

12

Ms

57%

Pra

yer

/spir

itual

(45Æ9

)

Her

bal

med

icin

e(1

6Æ2

)

Rel

axati

on

tech

niq

ues

(11Æ7

)

Chir

opra

ctic

(8Æ1

)

Folk

rem

edie

s(5

Æ1)

Mass

age

(6Æ9

)

Spec

ial

die

t(6

Æ8)

Meg

avit

am

ins

(5Æ9

)

Aro

mat

her

apy

(2Æ2

)

Sel

f-hel

pgro

up

(2Æ0

)

Cli

fford

etal

.(2

003),

Aust

rali

a

351

DM

(NM

)

Conven

ience

sam

ple

wit

hper

sonal

inte

rvie

w

Whic

hof

the

follow

ing

have

you

use

din

the

past

yea

r?(t

he

list

of

pro

duct

s

consi

der

edto

be

Com

ple

men

tary

med

icin

es)

12

Ms

23Æ6

%V

itam

inC

(18Æ0

)

Garl

ic(1

7Æ0

)

Fis

hoil

(14Æ0

)

Mult

ivit

am

ins

(12Æ0

)

Vit

am

inB

(11Æ0

)

Calc

ium

(8Æ0

)

Glu

cosa

min

e(1

0Æ0

)

Chro

miu

m(7

Æ0)

Gin

kgo

bil

oba

(6Æ0

)



Table

2(C

onti

nued

)

Auth

or

Countr

yn

(RR

)D

esig

nsa

mpling

Res

earc

hques

tion

Tim

efra

me

Use

rate

Popula

rth

erapie

sli

st(%

)

Al-

Sae

edi

etal

.(2

003),

Ara

bia

1039

DM

(89Æ4

%)

Random

sam

ple

wit

h

per

sonal

inte

rvie

w

Do

not

men

tion

(her

bal

rem

edie

s)

NM

30Æ1

%Fen

ugre

ek(6

Æ1)

Chin

aber

ryle

ave

s–

Nee

m

(5Æ1

)and

Ham

al

(4Æ8

)

Yel

low

wood

sorr

el

(1Æ9

)

Oli

ve

leave

s(1

Æ6)

Bit

ter

apple

(1Æ3

)

Radis

h(1

Æ0)

Arg

aez

-Lopez

etal

.

(2003),

Mex

ico

353

Typ

e2

dia

bet

es

(NM

)

Do

not

men

tion

Have

you

ever

use

dany

of

the

follow

ing

nin

e

ther

apie

s?

NM

62Æ0

%H

erbal

rem

edie

s(9

4Æ2

)

Opunti

a(7

3Æ1

)

Oth

ers

(5Æ8

)

Lee

etal

.(2

004),

Kore

an

223

DM

(87Æ8

%–97Æ1

%)

dif

fere

nt

sett

ing

Conven

ience

sam

ple

wit

h

self

-rep

ort

Have

you

ever

use

d

alt

ernati

ve

ther

apie

s?

Ali

stof

CA

Mw

asuse

d

for

furt

her

ques

tion

Lif

e-ti

me

65Æ0

%Pla

nt

der

ived

(63Æ7

)

Cer

eal

and

seed

(21Æ0

)

Ste

am

and

leave

s(2

1Æ0

)

Root

(15Æ8

)Fru

it(6

Æ7)

Flo

wer

(4)

Sea

wee

d(0

Æ8)

Anim

al

mate

rials

(21Æ6

)

Mea

t(1

6Æ4

)

Mari

ne

pro

duct

(5Æ2

)

Mis

cell

aneo

us

(14Æ7

)

Mix

edm

ate

rial

(8Æ5

)

Moola

sarn

etal

.(2

005),

Thail

and

159

DM

(98Æ1

%)

Conven

ience

sam

ple

wit

h

per

sonal

inte

rvie

w

Have

you

use

dC

AM

duri

ng

the

past

3m

onth

s?

3M

s47Æ0

%Y

oga/e

xer

cise

(46Æ0

)

Unch

anged

form

of

her

bal

med

icin

e(4

2Æ1

)

Changed

form

of

her

bal

med

icin

e(2

5Æ0

)

Acu

punct

ure

/

acu

pre

ssure

(10Æ5

)

Men

tal

ther

apy

(7Æ9

)

Die

tsu

pple

men

t(5

Æ3)

Oil

mass

age

(2Æ6

)

Oth

ers

(1Æ3

)

Arc

ury

etal

.(2

006),

rura

lU

SA

701

Eld

erly

wit

hdia

bet

es

(89%

)

Random

sam

ple

wit

h

per

sonal

inte

rvie

w

Have

you

use

dat

least

one

ther

apy

inea

chof

the

eight

CA

Mca

tegori

esin

the

past

yea

r?

12

Ms

NM

For

gen

eral

reaso

n

Oth

erhom

ere

med

ies

(56Æ0

)

Food

hom

ere

med

ies

(52Æ0

)

Vit

am

ins

(44Æ8

)

Min

erals

(17Æ3

)

CA

Mth

erapie

s(9

Æ9)

CA

Mpra

ctit

ioner

s(8

Æ4)

For

dia

bet

esre

aso

n

Food

hom

ere

med

ies

(11Æ9

)

Oth

erhom

ere

med

ies

(10Æ5

)

Vit

am

ins

(5Æ7

)

CA

Mth

erapie

s(2

Æ5)

Min

erals

(2Æ 4

)

Her

bs

(2Æ4

)

Lin

det

al.

(2006),

USA

20,7

22

DM

(NM

)

Cla

ims

data

from

two

larg

ein

sure

rs

CA

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ctit

ioner

use

by

insu

red

pati

ents

wit

h

dia

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es

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Ms

17Æ4

%C

hir

opra

ctors

(14Æ6

)

Lic

ense

dm

ass

age

ther

apis

t(3

Æ4)

Acu

punct

uri

sts

(1Æ4

)

Natu

ropath

y

physi

cians

(1Æ1

)

Kum

aret

al.

(2006),

India

493

DM

(NM

)

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emat

icsa

mpli

ng

wit

h

per

sonal

inte

rvie

w

New

case

sin

clin

ics

by

ass

essi

ng

thei

ruse

of

CA

M

india

bet

es

Curr

ent

67Æ7

%N

atu

ropath

y(9

7Æ3

)

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eda

(16Æ2

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eopath

y(1

2Æ9

)

Acu

pre

ssure

(2Æ7

)

Oth

ers

(3Æ0

)

H.-Y. Chang et al.


non-response rates and the choice of study sample (six of 13

studies used convenience sampling) (see Table 2). In addition,

recall bias may have occurred in retrospective studies. The

other problem that hinders comparison of studies of CAM

use is the size of the sample. For example, the sample sizes in

two US studies, while large overall, only included small

numbers of people living with diabetes and using CAM. In

Yeh et al.’s (2002) study there were only 53 people with

diabetes and only 62 people in Egede et al.’s (2002) study. It

would be very difficult to extrapolate an expected prevalence

within the larger population from these samples.

Due to the inconsistency in the definition of CAM and the

inconsistency of research design, considerable uncertainties

exist in regard to demonstrating the true prevalence of CAM

use by people with diabetes. Despite these limitations, several

interesting characteristics and consistent trends emerged

within this review that may inform nurse and patient

education, clinical practice and clinical research.

Prevalence of CAM use among people with diabetes

worldwide

The results of this literature review illustrate that prevalence

estimates vary widely, depending on the definition of CAM

and survey design used by researchers. Figure 1 shows the

prevalence of CAM use among people with diabetes outlined

in each of the studies. The results range from a low of 17% in

a study conducted in United Kingdom (UK) to a high of

72Æ8% in the newest data from the USA. The average

percentage of CAM use across populations living with

diabetes (45Æ53%) suggests that nearly half of people with

diabetes have used some form of CAM in conjunction

with conventional medicines.

The studies related to prevalence of biologically based

CAM use came from three studies conducted in Australia,

Arabia and Canada (Ryan et al. 2001, Al-Saeedi et al. 2003,

Clifford et al. 2003). These studies showed similar usage rates

ranging from 23Æ6% to 31% (see Figure 1). The remaining

studies from Thailand, the USA, Mexico, Korea, and India

investigated the whole spectrum of CAM use among people

with diabetes and demonstrated not surprisingly a higher

prevalence of CAM use with a range between 47Æ8% and

72Æ8% (Leese et al. 1997, Yeh et al. 2002, Argaez-Lopez et al.

2003, Lee et al. 2004, Moolasarn et al. 2005, Bell et al. 2006,

Garrow & Egede 2006, Kumar et al. 2006) (see Figure 1).

Only in one study (Lind et al. 2006), a survey of the use of

CAM practitioners, did the prevalence remain low (17Æ4%)

(see Table 2). On the basis of the data outlined in this review,

the prevalence of the whole spectrum of CAM use is clearly

greater than that of only ‘biologically based therapies’ orTable

2(C

onti

nued

)

Auth

or

Countr

yn

(RR

)D

esig

nsa

mpli

ng

Res

earc

hques

tion

Tim

efra

me

Use

rate

Popula

rth

erapie

slist

(%)

Garr

ow

and

Eged

e

(2006),

USA

>31,0

00

DM¼

2474

(NM

)

2002

Nati

onal

inte

rvie

w

surv

ey

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fere

nt

types

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epast

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itam

ins

(67Æ0

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Pra

yer

(67Æ0

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Her

bal

rem

edy

(22Æ0

)

Chir

opra

ctic

care

(21Æ0

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Rel

axati

on

tech

niq

ues

(17Æ0

)

Oth

erC

AM

s(1

4Æ0

)

Die

t-base

dth

erapie

s

(7Æ0

)

Yoga

(4Æ0

)

Bel

let

al.

(2006),

USA

30,7

85

DM

(99Æ2

%)

2002

Nati

onal

Inte

rvie

w

Surv

ey

Have

you

use

dth

e

foll

ow

ing

20

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M

ther

apie

sin

the

past

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r?

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f-pra

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(61Æ2

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(39)

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ral

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sts

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opra

ctic

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ling

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al

(4Æ2

)

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t-base

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erapie

s

(3Æ2

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avit

am

in(3

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CA

M,

com

ple

met

ary

and

alt

ernati

ve

med

icin

e;D

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dia

bet

esm

elli

tus;

Ms,

month

s;n,

num

ber

of

sam

ple

;N

M,

not

men

tioned

;R

R,

resp

onse

rate

.



‘CAM practitioners’. As mentioned before, while it is difficult

to estimate accurate prevalence figures for the population of

people living with diabetes worldwide, healthcare profes-

sionals should be aware that all the data suggest that a large

number of people with diabetes, in a wide variety of

countries, use CAM in addition to conventional medical

treatments.

Socio-demographic characteristics of CAM users with

diabetes

To identify which people with diabetes were more likely to

use CAM, comparison of the characteristics of CAM users

with non-users is necessary. The studies revealed a significant

relationship between age, duration of diabetes, the degree of

complications and self-monitoring blood glucose (SMBG)

and use of CAM. For example, people who had diabetes for

longer were more likely to perceive benefit from CAM, to use

CAM regularly and to use CAM for longer, than those newly

diagnosed (Leese et al. 1997, Ryan et al. 2001, Lee et al.

2004, Bell et al. 2006). Egede et al. (2002) identified those

aged over 65 years as being three times more likely to use

CAM than those aged <65 years. There are also other

factors associated with a higher likelihood of using CAM

reported in single studies, such as being female (Clifford et al.

2003), ethnicity (Arcury et al. 2006) and having a higher

educational background (Egede et al. 2002, Bell et al. 2006).

Table 3 Qualitative research reports related to complementary and alternative medicine (CAM) therapies used by people with diabetes

Author country Sample Method Research focus

Popular therapies

list

Hunt et al. (2000)

Mexican-American,

USA

43 Descriptive qualitative

study

Herbs and prayer Prayer

No specific herbs

Nopal

(cactus leaves)

Aloe vera

Nispero (loquat leaves)

Garlic

Diabetina (herb tea)

Miscellaneous herbs

Schoenberg et al. (2004),

USA


study

Types of CAM used by

older adults with

diabetes

Herbal remedies

Dietary remedies

Teas

Spiritual intervention

Any of the above

CAM others

Poss et al. (2003),

Mexican-American,

USA


study

Home remedies Prepare Tea

Diabetil tea

Diabe cure

Malabar tea

Huereque tea

Wereke tea

Creosote

Prickly pear cactus

(Opuntia)

Aloe vera

Agave spp.

Wild grapes

Job’s tear

Dunning (2003), Australia 10 Focus groups Types of CAM used by

adults with diabetes

Aromatherapy/or

massage

Herbal medicines

Massage

Meditation

Naturopathy

Nutritional therapies and

supplements

Traditional Chinese

medicine

Jones et al. (2006), rural

African-Americans


study Focus group

Types of CAM used by

adults with type 2

diabetes

Prayer

Diet-based

therapies

Lemon juice

Vinegar

Natural product

Teas from leaves and roots

Herbal supplements

0

20

40

60

80

UK

Australia

Arabia

Canada

Thailand

2002 US

A

Mexico

Korea

India

2006 US

A

Figure 1 Prevalence of complementary and alternative medicine

(CAM) use among people with diabetes worldwide (based on Leese

et al. 1997, Ryan et al. 2001, Yeh et al. 2002, Al-Saeedi et al. 2003,

Argaez-Lopez et al. 2003, Clifford et al. 2003, Lee et al. 2004,

Moolasarn et al. 2005, Bell et al. 2006, Kumar et al. 2006).

H.-Y. Chang et al.


Interestingly, receiving a diabetes education programme

was associated with a higher use of CAM in Korea (Lee et al.

2004). Similarly, it was found in Australia that people

completing a home blood glucose monitoring diary are more

likely to use CAM (Clifford et al. 2003). Hunt et al. (2000)

explained this by indicating that people who are highly

motivated to control their diabetes usually engage in an

earnest effort to try all types of CAM available to them. It

also has been identified in scientific studies that people view

CAM as less authoritarian, more empowering and as offering

them more personal autonomy and control over their

healthcare decisions (Astin 1998, Thorne et al. 2002). The

findings indicate that people actively engage in the use of

CAM as a strategy for health self-management. Nowadays,

diabetes care focuses on self-management with patients and

healthcare professionals collaborating as equals. Therefore,

assisting patients in the assessment of potential benefits,

adverse effects and potential interactions of CAMs with

conventional medicine, when used concomitantly, is an

essential role of healthcare professionals.

Common types of CAM used by people with diabetes

When examining which CAM are most frequently used by

people with diabetes, there are two major kinds of surveys:

those that include the whole spectrum of CAM and those that

include only ‘biologically based therapies’. The studies that

focus only on biologically based CAMs were conducted in

Canada and Australia. They display similar results, for

example, the most frequently used biologically based CAM

were: vitamins (most frequently used were multivitamins and

vitamins B and C); nutritional supplements (fish oil, glucosa-

mine and calcium); and herbal medicines (garlic, echinacea

and ginkgo) (Ryan et al. 2001, Clifford et al. 2003). The other

surveys included the whole spectrum of CAM therapies used

in countries such as the USA and Thailand and those most

frequently used for diabetes were prayer/spiritual practice,

herbal medicines, relaxation techniques, chiropractic, nutri-

tional advice and massage (Egede et al. 2002, Moolasarn et al.

2005, Arcury et al. 2006, Bell et al. 2006). However, countries

with a long tradition of alternative health systems such as

Arabia, Mexico and Korea reported regimens ranging widely

from plant derived to animal materials, such as fenugreek,

opuntia, and silk worm (Argaez-Lopez et al. 2003, Lee et al.

2004, Moolasarn et al. 2005). This phenomenon may occur

because when people choose a particular CAM, they are

usually attracted to options congruent with their values,

culture and world view (Vincent & Furnham 1996, Astin

1998, Dunning 2003). All the popular CAM therapies

outlined in each study are presented in Tables 2 and 3.

Even though the common types of CAM may differ from

country to country, the distribution among diabetic popula-

tions seems to follow a common pattern. The most frequently

used CAMs have been identified as: nutritional supplements,

herbal medicines, nutritional advice, spiritual healing, and

relaxation techniques. Reflecting on these common patterns,

it seems that living with the continual burden of blood

glucose testing, following particular eating habits, injecting

insulin, feeling different from normal, facing complications

and coming to terms with their own mortality has a

significant effect on the patient’s quality of life; often

engendering fear and powerlessness; and can compromise

physical and psychological functioning (Dunning 2003).

Importantly, since providing people with appropriate recom-

mendations, so they can make informed decisions is a

significant aspect of nursing care; nurses need to seek

evidence-based information regarding CAM for the manage-

ment of diabetes in order to assist people with diabetes to use

CAMs safely and to plan a suitable approach to achieve

maximal blood glucose control.

Disclosure of CAM use to healthcare professionals

Safety of CAM use is an important issue from the point of

view of people using these medicines and healthcare profes-

sionals, particularly because of the growing popularity of

CAM use among people with diabetes. Although CAM is not

presently considered as part of conventional medicine, the

majority of patients use CAM along with conventional

medicine rather than in place of it. Problematically, the

extent to which people disclose their use of CAM to their

physicians actually remains low. However, only four out of

the 13 studies included in this review reported on the issue of

the disclosure of CAM use to healthcare professionals. In the

USA, the non-disclosure rate (43%) (Egede et al. 2002) is

lower than in countries such as Mexico (64%) (Argaez-Lopez

et al. 2003) and Thailand (64Æ4%) (Moolasarn et al. 2005).

In one qualitative study, conducted by Dunning (2003) in

Australia (see Table 3), only one of 10 participants had

informed conventional health professionals of CAM use;

however, all participants had informed their CAM therapist

that they had diabetes, and detailed the medications they

were taking. There is an opportunity for nursing staff to

make a difference by taking time in patient assessment and

displaying an attitude that encourages people to disclose their

CAM use.

Patients usually expressed the attitude that CAM may not

help much, but will probably not hurt, provided they

continue with the conventional treatments recommended by

their physicians (Hunt et al. 2000). Contrary to this popular



belief, several case reports indicated that the use of both

herbal medicine and conventional medicine resulted in the

adverse effects from herb–drug interaction (Gill et al. 1994,

Dunning et al. 2001, Goudie & Kaye 2001, Wood et al.

2004). For example, Clifford et al. (2003) reported that, of

people with diabetes, >43% who used CAM had the

potential for herb–drug interaction, and required extra

monitoring for the adverse effects. Therefore, a responsible

healthcare approach is that patients should receive evidence-

based CAM information about efficacy, effectiveness, adverse

effects and possible interactions, to inform their decision-

making related to CAM use.

Implications for nursing

The high levels of CAM use, reported in the studies

summarized in Tables 2 and 3, highlight the need for an

evidence-based assessment of CAM. This is necessary because

all of these therapies and medicines have their own potential

benefits and potential interactions with conventional treat-

ments and should be evaluated for quality, safety and efficacy

before use. Common herbal medicines used by people with

diabetes include ginseng, bitter melon, fenugreek and nutri-

tional supplements such as chromium, magnesium and fish oil

(Ezzo et al. 2001, Yeh et al. 2003, Manyam 2004). Table 1

presents an overview of commonly used medicinal herbs and

nutritional supplements; however, this list is not a complete

review of CAMs used in diabetes. More than 1000 traditional

plants have been claimed to benefit treatment of diabetes

worldwide (Day 2005), but not all of these have been

thoroughly investigated. Several comprehensive reviews sum-

marize the evidence for the use of numerous plants and

supplements such as fish oil in the treatment of diabetes

(Farmer et al. 2001, Shane-McWhorter 2001, Yeh et al.

2003). CAM therapies commonly used for the treatment of

diabetes include traditional Chinese medicine, yoga and

massage. However, no recent reviews of the evidence of

some CAM therapies such as acupuncture exist, although

initial studies suggest beneficial effects, for example in

diabetes related peripheral neuritis (Jiang et al. 2006).

This literature review not only assists nurses and other

healthcare professionals to understand the prevalence of

CAM use among people with diabetes, but also to raise the

issue of non-disclosure of CAM use to healthcare profession-

als and the resultant potential risks. Nurses need to be aware

of the possibility that their patients are using CAM therapies;

particularly, as they are often the patient’s first point of

contact within the healthcare system, and thus may under-

take the first assessment of the patient’s healthcare practices.

Essentially, nurses need knowledge about CAM in order to

undertake a complete health assessment, to identify which

CAMs have benefit for people with diabetes and potential

CAM–drug interactions, and to be able to inform physicians

and other healthcare professionals about their patients’ CAM

use (Cuellar et al. 2003).

The increased presence of CAM-related courses in medical

and nursing curricula is apparent in the USA and Canada, as

well as other countries (Haramati & Lumpkin 2004);

however, most CAM courses in a curriculum are electives

(Dutta et al. 2003) and few are offered in the baccalaureate

level programmes (Burke et al. 2004). Several research studies

indicated that the majority of healthcare professionals still

consider their knowledge insufficient to meet current needs

regarding answering their patients’ questions and appro-

priately referring them to reputable CAM practitioners

(DeKeyser et al. 2001, Fearson 2003, Wetzel et al. 2003).

Thus, up-to-date education on CAM within undergraduate

and postgraduate programmes and ongoing professional

development is imperative. For example, future nursing

curricula should include content on the efficacy and effect-

iveness of CAMs used by people with diabetes, possible toxic

effects and potential interactions with other medicines.

In future CAM surveys it is imperative that definitions and

methods are employed consistently to enable clinicians and

researchers to compare results across a number of studies. It

is important for researchers to use the most common

definition of CAM and the categories of CAM as defined

by NCCAM. It would also be helpful if researchers were to

survey and report separately on CAM therapist consultations

and the use of CAMs, as well as on point prevalence and

lifetime prevalence of use.

Most of the studies included in this review did not question

participants about their reasons for using CAM (Leese et al.

1997, Ryan et al. 2001, Argaez-Lopez et al. 2003, Clifford

et al. 2003). Ninety-one per cent, however, of participants in

Leese et al.’s (1997) study used CAM for non-diabetes-related

problems, while only 35% reported use specifically for

diabetes in Yeh et al.’s (2002) study. Future research needs

to include questions about reason for use of as well as type of

CAM used and frequency.

In order to assist healthcare professionals in the under-

standing of the culture of diabetes care, future studies might

benefit from using cultural frameworks such as the explan-

atory model of illness to explore the illness experience and the

role of CAM use in coping with chronic illness. While there is

currently some information available about which CAMs are

used by people with diabetes, further research needs to focus

on the patterns of use, the predictors of use, the factors

affecting communication with health professionals and the

efficacy and effectiveness of commonly used CAMs.

H.-Y. Chang et al.


Conclusion

Diabetes mellitus is a chronic illness, and a leading cause of

death, disability and hospitalization. Since this chronic

disease affects the entirety of a person’s being, seeking

treatment through CAM approaches has become a strategy

used to improve well-being. Although there are considerable

uncertainties in regard to demonstrating the true prevalence

of CAM use among diabetic populations worldwide, due to

the inconsistency in the definition of CAM and the inconsis-

tency of research design, this literature review illustrates a

high level of CAM use among people with diabetes attending

conventional healthcare services in different countries and

regions. Additionally, a significant relationship between

CAM use and age, duration of DM, the degree of compli-

cations and SMBG has been revealed.

Although evidence supports the notion that people with

diabetes are using CAM as a supplementary means of

treating their disease, a substantial gap exists in their

attitudes related to communicating CAM use to healthcare

professionals. This may cause disease mismanagement when

healthcare professionals are unaware of CAM use.

Therefore, healthcare professionals must be aware of the

increase in the number of patients who use CAM while

under conventional care.

Through diabetes patient education programmes, nurses

are the members of healthcare team who work most closely

with people with diabetes in taking control of their disease,

especially in aiming to empower people to self-manage their

diabetes. However, if nurses do not consider the patient’s

background, health history, health beliefs and cultural

diversity, it would be difficult to address that patient’s health

problems and plan specific strategies designed to modify

lifestyle. Accepting that people with diabetes try CAM and

helping them sort through the many available choices are

important roles for nurses among other healthcare profes-

sionals. Therefore, understanding CAM therapies and their

integration into conventional medicine is needed in order to

ensure patient safety and optimize health care.

Author contributions

HC, MW and ET were responsible for the study conception

and design and the drafting of the manuscript. HC, MW and

ET made critical revisions to the paper. MW and ET

supervised the study.

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