JAN REVIEW PAPER

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 C H A N G H . - Y . , W A L L I S M . & T I R A L O N G O E ( 2 0 0 7 ) Use of complementary and

PhD Candidate alternative medicine among people living with diabetes: literature review. Journal of
School of Nursing and Midwifery, Griffith Advanced Nursing 58(4), 307–319
University, Gold Coast, Queensland,
doi: 10.1111/j.1365-2648.2007.04291.x
Australia

Marianne Wallis BSc PhD RN Abstract

Professor of Clinical Nursing Research Title. Use of complementary and alternative medicine among people living with
Griffith University Research Centre for diabetes: literature review
Clinical Practice Innovation and Gold Coast Aim. This paper is a report of a literature review to explore the prevalence of
Health Service District, Queensland, complementary and alternative medicine use amongst people with diabetes to in-
Australia form nursing practice, education and research.
Background. Diabetes mellitus affects the entirety of a person’s being and increas-
Evelin Tiralongo BPharmSc PhD
ingly people use complementary and alternative medicine in conjunction with other
Lecturer
School of Pharmacy, Griffith University Gold medical treatments and lifestyle modifications to manage their condition and
Coast, Queensland, Australia improve well-being.
Methods. The CINAHL, Medline, ProQuest nursing journals and Psych INFO
Correspondence to Hsiao-yun Chang: databases were searched for the period 1990–2006 using identified keywords.
e-mail: [email protected] 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

world. Population-based studies in countries in the developed

Introduction
world, such as Australia, Scotland, UK, Taiwan, Singapore
Interest in and use of complementary and alternative medicine and the United States of America (USA), report that one-half
(CAM) has recently expanded in many countries around the to two-thirds of adults use CAM (Emslie et al. 1996,

 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd 307
H.-Y. Chang et al.

MacLennan et al. 2002, Lew-Ting 2003, Lim et al. 2005, (4) Manipulative and body-based methods: these are based
Tindle et al. 2005). This significant CAM usage in the general on the movement of one or more body parts, such as
population can be expected to lead to a demand for informa- chiropractic, osteopathic and massage.
tion on CAM usage by the clients of health professionals. (5) Energy therapies: these involve the use of energy fields
The presence of chronic, debilitating or painful illness has that are believed to surround and penetrate the human
consistently been found to be a reason people seek out CAM body, such as biofield therapies (Gi Gong and Thera-
(Eisenberg et al. 1998). Diabetes mellitus (DM) is one such peutic Touch); and bioelectromagnetic-based therapies
disease which is highly prevalent worldwide. The mortality (pulse fields and magnetic fields).
associated with diabetes is significant, and primarily arises Despite the diverse ways in which these systems and
from complications of long-standing hyperglycaemia. therapies have developed, they share common themes, such
Around 3Æ2 million deaths every year worldwide are attrib- as the use of complex interventions; individual diagnosis;
utable to complications of diabetes, which equates to six belief in the healing power of nature; union of mind, body
deaths every minute (World Health Organization 2004). and spirit; and more holistic and integrative approaches to
Conventional medicine for diabetes has been geared toward individualized treatment plans. Several comprehensive
regulating blood glucose with a combination of dietary reviews have been written on the evidence that CAM
modification, insulin and/or oral agents, maintaining ideal therapies can be beneficial for the management of diabetes
body weight, exercising regularly and self-monitoring blood (Goguen & Leiter 2001, Shane-McWhorter 2001, Dey et al.
sugar. Good glucose control can, however, be difficult for 2002, Liu et al. 2002, Yeh et al. 2003). For example, a
many people with diabetes, because these conventional number of herbal medicines and nutritional supplements have
treatment plans require changes to behaviour and lifestyle been shown to decrease blood glucose level through various
(Dunning 2003). Due to the chronic course of the disease, the mechanisms, and if used correctly, these effects can help
debilitation of complications and threat of death, as well as people with diabetes to manage their disease and to improve
the complexities of treatment plans, people with diabetes their quality of life (see Table 1). However, while evidence is
often work proactively to manage their condition, optimize mounting in support of the use of various CAMs to treat
their health and alleviate complications through the use of diabetes and its complications, it is unclear how many people
CAM (Yeh et al. 2002, Dunning 2003, Bell et al. 2006). with diabetes use CAM and whether they use the CAMs that
Complementary and alternative medicine refers to prac- are beneficial for diabetes management.
tices, approaches, knowledge and beliefs incorporating plant,
animal and mineral-based medicines, spiritual therapies,
Aim
manual techniques and exercises (World Health Organization
2003). A variety of definitions and descriptions are used to The aim of the review was to explore the prevalence of CAM
explain CAM. The most broadly used functional definition of use amongst diabetic populations in order to inform nursing
CAM has been developed by the National Centre for practice, education and research.
Complementary and Alternative Medicine (NCCAM) in the
USA. This definition states that ‘CAM is a group of diverse
Search methods
medical and healthcare systems, practices and products that
are not presently considered to be part of orthodox medicine’
Databases and keywords
(NCCAM 2002, p. 1). CAM is a categorical term that
encompasses a broad spectrum of medicines, therapies and The following databases were searched for the period 1990
practices. The NCCAM categorized CAM into five major to October 2006: CINAHL, Medline, ProQuest nursing
domains: journals and Psych INFO. The keywords used were com-
(1) Alternative medical systems: these are built upon com- plementary and alternative medicine, complementary medi-
plete systems of theory and practice, such as homeopathic cine, complementary therapy and alternative medicine (and
medicine and traditional Chinese medicine. related terms such as traditional medicine, folk medicine
(2) Mind–body interventions: these use a variety of tech- and unconventional/non-conventional medicine), prevalence
niques designed to enhance the mind’s ability, such as and DM. Some papers were found through tracking citations
meditation, prayer and art therapies. from other publications. Inclusion criteria were prevalence
(3) Biologically based therapies: these use substances found studies of CAM use by people with diabetes and other
in nature, such as dietary supplements, herbal products research reports of studies exploring CAM use by people
and botanical products. with diabetes. Exclusion criteria were: publication in a

308  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
JAN: REVIEW PAPER Use of complementary and alternative medicine people with diabetes

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

Potential interactions and

Herbal medicines Effects contraindications References

Bitter melon Hypoglycaemic activity Hypoglycaemic agents Basch et al. (2003)

(Momordica charantia) Pregnancy
Fenugreek Hypoglycaemic activity Hypoglycaemic agents Yeh et al. (2003)
(Trigonella foenum graecum) Lipid-lowering effects Pregnancy
Increased HDL cholesterol Anticoagulant drugs.
MAO inhibitors
Ginseng (Panax ginseng) Hypoglycaemic activity Hypoglycaemic agents Sievenpiper et al. (2004)
Improved psycho-physiological Corticosteroids
performance Oral contraceptives
Immune stimulant effects Anticoagulant drugs
Digoxin
MAO inhibitors and tricyclic
antidepressants
Diuretics
Ginkgo (Ginkgo biloba) Antioxidant, Neuroprotective Anticoagulant drugs Shane-McWhorter (2001)
Beneficial in cerebrovascular SSRI
insufficiency and peripheral MAO inhibitors
vascular disease Herbs: ginger, garlic and feverfew
Supplements
Chromium Increased insulin sensitivity N/A Guerrero-Romero and
Lipid-lowering effects Rodriguez-Moran (2005)
Fish oil Triglyceride-lowering effects Pregnant or breastfeeding Farmer et al. (2001),
Anti-inflammatory Anticoagulant drugs Pittler and Ernst (2005)
Anti-platelet Anti-hypertension drugs
Hypotensive
Magnesium Essential in glucose metabolism Antibiotics Guerrero-Romero and
Prevent diabetic complications Drugs to prevent osteoporosis Rodriguez-Moran (2005)
Calcium channel blockers
Muscle relaxants
Diuretics
Zinc Metalloenzyme activitor Reduce absorption folic acid, Franz et al. (2002)
Immune function tetracyclines, copper
Improved insulin levels Reduce the effect of therapies that rely on
Lipid-lowering effects dopamine receptor antagonists
Improved weight loss Vitamin A

language other than English; not available by inter-library of terms or because they included information about disclo-
loan service in Australia; and publication dates before 1990 sure to healthcare professionals.
as this was when the increasing use of CAM began to be
reported.
Results
The search produced 232 abstracts. This number was further
Review limitations
reduced by selecting research-based papers, specifically those
This review included research-based studies focusing on studies related to the prevalence of CAM use and those
CAM use among people with diabetes. As this was not a related to the types of CAM commonly used by people with
systematic review of efficacy, expert judgement rather a diabetes. This resulted in 18 papers being selected for
formal quality appraisal was used to determine which studies inclusion in the review. Thirteen reported quantitative studies
were included. Some studies which demonstrated design, that related to prevalence of CAM use and type of CAM used
selection and measurement bias were included because they by people with diabetes. Five reported qualitative studies
provided useful insights into either the problems in definition related to the type of CAM used by people with diabetes. The

 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd 309
H.-Y. Chang et al.

remaining papers were either not research-based studies or The second problem regarding the operational definition of
not related to the purpose of this literature review. All the CAM is the manner in which different researchers categorize
included studies were reviewed and compared, then sum- CAM. Rather than using the NCCAM’s domains, some
marized in a matrix form, in terms of the aims of the review. researchers use other conceptual models; for example, in the
The key data from the 18 publications covered in this Lee et al. (2004) study, biologically based therapies were
review are summarized in Tables 2 and 3. Most of the studies further categorized in terms of the origin of the CAM
were published between 2000 and 2006 with only one study product, such as plant-derived, animal materials and miscel-
published during the 1990s. Publications were based on laneous.
studies conducted in nine countries. The majority of papers The third problem that arose when attempting to compare
were derived from the USA (nine studies) and Australia (two the selection of CAM therapies used in studies, was the lack
studies). Most of the studies were conducted in developed of consistency with which CAMs were included in the
countries with respondents recruited from conventional investigation. For example, some studies focus only on the
hospitals. Unfortunately, data from Europe were limited, usage of the ‘biologically based therapies’ such as vitamins,
because there were either none reported in English or no nutritional supplements and herbal medicine, whereas a
studies conducted. Although this is a limitation, the present number of surveys included the whole spectrum of CAM
review summarizes the available data on the prevalence of therapies. Only one study (Lind et al. 2006) reported
CAM use among people with diabetes worldwide. 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
Challenges in interpreting the published literature
list’. Because of a lack of consistency in categorization of
The papers reviewed report a high level of CAM use in people CAM therapies and a lack of consensus about which type and
with diabetes attending conventional healthcare services in how many therapies should be examined, it is difficult to
different countries and regions. The comparison of CAM use make an accurate evaluation of the frequency with which
prevalence data between these studies is difficult, however, CAM therapies are used.
because these studies differ markedly in their definitions of A variety of research designs have been used in an attempt
CAM, research design, methods of data collection, time- to assess CAM use among people with diabetes. When
frames and response rates. reviewing the literature on the prevalence of CAM use, a
Defining the term CAM is not an easy task. Murphy et al. number of important caveats have to be considered, such as
(2003) searched biomedical databases on CAM to estimate the fact that each survey covers a slightly different timeframe,
the degree to which the literature displays the use of selection criteria vary and the methods of recruitment vary
controlled vocabulary among authors, indexers, and inves- (Ernst 1999). Some surveys were aimed at determining
tigators, and concluded that validity of the definition of lifetime prevalence of CAM use, while others used 1 year
CAM was the most difficult search concept, largely due to or current use data. These differences may be seen in the
inconsistent use of terminology between studies. As Table 2 column of ‘timeframe’ in Table 2. Some researchers, such as
demonstrates, the reviewed research studies provided limited Leese et al. (1997), Al-Saeedi et al. (2003), Argaez-Lopez
information about the instruments used. Each study had its et al. (2003) and Ryan et al. (2001) did not mention the
own operational definition of CAM and there were differ- timeframe at all. In the studies that investigated lifetime
ences between the specific types of therapy included as prevalence of CAM use there was limited reporting of the
CAM, which therapies were classified into which subcate- measures taken to minimize recall bias.
gory and how many CAMs were investigated. For example, Another issue of considerable importance in comparing
the studies of Ryan et al. (2001), Yeh et al. (2002), Garrow and contrasting previous studies is the difference in meth-
and Egede (2006) and Bell et al. (2006) used different odological approaches undertaken by researchers. To enable
criteria to determine whether vitamins or mineral supple- high response rates, survey questions are necessarily short
mentation were defined as a form of CAM and thus, and uncomplicated (Harris & Rees 2000). Self-reported
included in the survey. If some studies had included all types questionnaires and telephone interviews, in particular, are
of vitamins not just mega-vitamins, the reported CAM use dependent for accuracy, upon respondents’ knowledge of
could be much higher than the original data. In comparison CAM therapies, and/or their willingness to report that use. As
with these studies, electrotherapy, exercise, special diet a consequence, the quality of data related to the prevalence of
control and psychotherapy seldom came under the umbrella CAM use may be influenced by these factors. Additionally,
of CAM. most studies had selection biases as a result of high

310  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
 Table 2 Quantitative research reports related to complementary and alternative medicine (CAM) therapies used by people with diabetes mellitus (DM)

Author Country n (RR) Design sampling Research question Timeframe Use rate Popular therapies list (%)

Leese et al. (1997), 246 Convenience sample Patients attending the NM 17% Acupuncture (n ¼ 18) Hypnotherapy
UK DM (75%) with personal diabetes clinic assessed Homeopathy (n ¼ 11) (n ¼ 3)
interview the utilization of CAM Herbal therapy (n ¼ 7) Celluar nutrition
JAN: REVIEW PAPER

Reflexology (n ¼ 4) (n ¼ 2)
Aromatherapy (n ¼ 4) Chiropractor
(n ¼ 2)
Others (n ¼ 5)
Ryan et al. (2001), 703 Non-random sample What kind of medication NM AM 31% OTC supplements Alternative medicines
Canada DM ¼ 502 52% personal interview presently in use of OTCS 44% Multivitamins (27Æ5) Garlic (11Æ6)
Non-DM ¼ 201 48% telephone interview over-the-counter Vitamin E (18Æ9) Echinacea (8Æ9)
(NM) supplements (OTCS) and Vitamin C (18Æ7) Herbal mixtures
another medication (AM)? Calcium (16Æ0) (8Æ5)
Aspirin (13Æ9) Glucosamine (5Æ8)
Vitamin B Complex Chromium (5Æ8)
(6Æ5) Ginkgo biloba (4Æ9)
Egede et al. (2002), 21,571 Nationally representative Have you seen an 12 Ms NM Five common type of Provider of CAM
USA DM ¼ 825 (77Æ7%) sample with household alternative healthcare CAM Clergy/spiritualist
interview provider such as those Nutritional advice (n ¼ 18)
listed? (n ¼ 37) Massage therapist

 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd

Herbal remedies (n ¼ 16)
(n ¼ 20) Nurse (n ¼ 13)
Spiritual healing Acupuncturist
(n ¼ 21) (n ¼ 9)
Massage therapy
(n ¼ 19)
Mediation training
(n ¼ 14)
Yeh et al. (2002), USA 2055 Nationally representative Have you ever used any of 12 Ms 57% Prayer/spiritual (45Æ9) Massage (6Æ9)
DM ¼ 96 (NM) sample with telephone the following 16 Herbal medicine (16Æ2) Special diet (6Æ8)
interview therapies? Relaxation techniques Megavitamins (5Æ9)
If so, have you done so (11Æ7) Aromatherapy (2Æ2)
within the last 12 months? Chiropractic (8Æ1) Self-help group (2Æ0)
Folk remedies (5Æ1)
Clifford et al. (2003), 351 Convenience sample Which of the following 12 Ms 23Æ6% Vitamin C (18Æ0) Vitamin B (11Æ0)
Australia DM (NM) with personal have you used in the past Garlic (17Æ0) Calcium (8Æ0)
interview year? (the list of products Fish oil (14Æ0) Glucosamine (10Æ0)
considered to be Multivitamins (12Æ0) Chromium (7Æ0)
Complementary Ginkgo biloba (6Æ0)
medicines)

311
Use of complementary and alternative medicine people with diabetes
312
Table 2 (Continued)

Author Country n (RR) Design sampling Research question Timeframe Use rate Popular therapies list (%)
H.-Y. Chang et al.

Al-Saeedi et al. (2003), 1039 Random sample with Do not mention (herbal NM 30Æ1% Fenugreek (6Æ1) Yellow wood sorrel
Arabia DM (89Æ4%) personal interview remedies) Chinaberry leaves – Neem (1Æ9)
(5Æ1) and Hamal (4Æ8) Olive leaves (1Æ6)
Bitter apple (1Æ3)
Radish (1Æ0)
Argaez-Lopez et al. 353 Do not mention Have you ever used any of NM 62Æ0% Herbal remedies (94Æ2) Others (5Æ8)
(2003), Mexico Type 2 diabetes the following nine Opuntia (73Æ1)
(NM) therapies?
Lee et al. (2004), 223 Convenience sample with Have you ever used Life-time 65Æ0% Plant derived (63Æ7) Animal materials
Korean DM (87Æ8%–97Æ1%) self-report alternative therapies? Cereal and seed (21Æ0) (21Æ6)
different setting A list of CAM was used Steam and leaves (21Æ0) Meat (16Æ4)
for further question Root (15Æ8) Fruit (6Æ7) Marine product (5Æ2)
Flower (4) Seaweed (0Æ8) Miscellaneous (14Æ7)
Mixed material (8Æ5)
Moolasarn et al. (2005), 159 Convenience sample with Have you used CAM 3 Ms 47Æ0% Yoga/exercise (46Æ0) Acupuncture/
Thailand DM (98Æ1%) personal interview during the past 3 months? Unchanged form of acupressure (10Æ5)
herbal medicine (42Æ1) Mental therapy (7Æ9)
Changed form of herbal Diet supplement (5Æ3)
medicine (25Æ0) Oil massage (2Æ6)
Others (1Æ3)
Arcury et al. (2006), 701 Random sample with Have you used at least one 12 Ms NM For general reason For diabetes reason
rural USA Elderly with diabetes personal interview therapy in each of the Other home remedies (56Æ0) Food home remedies
(89%) eight CAM categories in Food home remedies (52Æ0) (11Æ9)
the past year? Vitamins (44Æ8) Other home remedies
Minerals (17Æ3) (10Æ5)
CAM therapies (9Æ9) Vitamins (5Æ7)
CAM practitioners (8Æ4) CAM therapies (2Æ5)
Minerals (2Æ4)
Herbs (2Æ4)
Lind et al. (2006), 20,722 Claims data from two CAM practitioner use by 12 Ms 17Æ4% Chiropractors (14Æ6) Acupuncturists (1Æ4)
USA DM (NM) large insurers insured patients with Licensed massage Naturopathy
diabetes therapist (3Æ4) physicians (1Æ1)
Kumar et al. (2006), 493 Systematic sampling with New cases in clinics by Current 67Æ7% Naturopathy (97Æ3) Acupressure (2Æ7)
India DM (NM) personal interview assessing their use of CAM Ayurveda (16Æ2) Others (3Æ0)
in diabetes Homeopathy (12Æ9)

 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd

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

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

Chiropractic care (6Æ8)

Relaxation techniques

Relaxation techniques
Diet-based therapies

Diet-based therapies
Acupuncturists (1Æ4)
Other CAMs (14Æ0)

Healing ritual (4Æ2)

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

Megavitamin (3Æ1)
recall bias may have occurred in retrospective studies. The
other problem that hinders comparison of studies of CAM

Yoga (4Æ0)
use is the size of the sample. For example, the sample sizes in
(17Æ0)

(12Æ7)
(7Æ0)

(3Æ2)
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
Timeframe Use rate Popular therapies list (%)

Chiropractic care (21Æ0)

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

Herbal remedy (22Æ0)

non-mineral) (15Æ7)
Prayer group (16Æ2) would be very difficult to extrapolate an expected prevalence
Other prayer (39)
Self-prayer (61Æ2)

Natural product
Vitamins (67Æ0)

within the larger population from these samples.

(non-vitamin,

CAM, complemetary and alternative medicine; DM, diabetes mellitus; Ms, months; n, number of sample; NM, not mentioned; RR, response rate.
Prayer (67Æ0)

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
48Æ0%

72Æ8%

interesting characteristics and consistent trends emerged

within this review that may inform nurse and patient
education, clinical practice and clinical research.
12 Ms

12 Ms

Prevalence of CAM use among people with diabetes

worldwide
different types of CAM

The results of this literature review illustrate that prevalence

following 20 CAM

estimates vary widely, depending on the definition of CAM

Have you used the
Research question

in the past year?

Collected over 17

therapies in the

and survey design used by researchers. Figure 1 shows the

prevalence of CAM use among people with diabetes outlined
past year?

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
2002 National Interview
2002 National interview

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

diabetes have used some form of CAM in conjunction
Design sampling

with conventional medicines.

The studies related to prevalence of biologically based
Survey

CAM use came from three studies conducted in Australia,

survey

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
DM ¼ 2474 (NM)

investigated the whole spectrum of CAM use among people

with diabetes and demonstrated not surprisingly a higher
DM (99Æ2%)

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

Garrow and Egede >31,000

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

30,785
n (RR)

2003, Lee et al. 2004, Moolasarn et al. 2005, Bell et al. 2006,
Table 2 (Continued)

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

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

Author Country

(2006), USA

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
USA

greater than that of only ‘biologically based therapies’ or

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H.-Y. Chang et al.

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

Popular therapies
Author country Sample Method Research focus list

Hunt et al. (2000) 43 Descriptive qualitative Herbs and prayer Prayer Nispero (loquat leaves)
Mexican-American, study No specific herbs Garlic
USA Nopal Diabetina (herb tea)
(cactus leaves) Miscellaneous herbs
Aloe vera
Schoenberg et al. (2004), 80 Descriptive qualitative Types of CAM used by Herbal remedies Spiritual intervention
USA study older adults with Dietary remedies Any of the above
diabetes Teas CAM others
Poss et al. (2003), 22 Descriptive qualitative Home remedies Prepare Tea Creosote
Mexican-American, study Diabetil tea Prickly pear cactus
USA Diabe cure (Opuntia)
Malabar tea Aloe vera
Huereque tea Agave spp.
Wereke tea Wild grapes
Job’s tear
Dunning (2003), Australia 10 Focus groups Types of CAM used by Aromatherapy/or Naturopathy
adults with diabetes massage Nutritional therapies and
Herbal medicines supplements
Massage Traditional Chinese
Meditation medicine
Jones et al. (2006), rural 68 Descriptive qualitative Types of CAM used by Prayer Natural product
African-Americans study Focus group adults with type 2 Diet-based Teas from leaves and roots
diabetes therapies Herbal supplements
Lemon juice
Vinegar

80 number of people with diabetes, in a wide variety of

countries, use CAM in addition to conventional medical
60 treatments.

40 Socio-demographic characteristics of CAM users with

diabetes
20
To identify which people with diabetes were more likely to
0 use CAM, comparison of the characteristics of CAM users
UK

Australia

Arabia

Canada

Thailand

2002 USA

Mexico

Korea

India

2006 USA

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
Figure 1 Prevalence of complementary and alternative medicine
longer were more likely to perceive benefit from CAM, to use
(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, CAM regularly and to use CAM for longer, than those newly
Argaez-Lopez et al. 2003, Clifford et al. 2003, Lee et al. 2004, diagnosed (Leese et al. 1997, Ryan et al. 2001, Lee et al.
Moolasarn et al. 2005, Bell et al. 2006, Kumar et al. 2006). 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
‘CAM practitioners’. As mentioned before, while it is difficult factors associated with a higher likelihood of using CAM
to estimate accurate prevalence figures for the population of reported in single studies, such as being female (Clifford et al.
people living with diabetes worldwide, healthcare profes- 2003), ethnicity (Arcury et al. 2006) and having a higher
sionals should be aware that all the data suggest that a large educational background (Egede et al. 2002, Bell et al. 2006).

314  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
JAN: REVIEW PAPER Use of complementary and alternative medicine people with diabetes

Interestingly, receiving a diabetes education programme Even though the common types of CAM may differ from
was associated with a higher use of CAM in Korea (Lee et al. country to country, the distribution among diabetic popula-
2004). Similarly, it was found in Australia that people tions seems to follow a common pattern. The most frequently
completing a home blood glucose monitoring diary are more used CAMs have been identified as: nutritional supplements,
likely to use CAM (Clifford et al. 2003). Hunt et al. (2000) herbal medicines, nutritional advice, spiritual healing, and
explained this by indicating that people who are highly relaxation techniques. Reflecting on these common patterns,
motivated to control their diabetes usually engage in an it seems that living with the continual burden of blood
earnest effort to try all types of CAM available to them. It glucose testing, following particular eating habits, injecting
also has been identified in scientific studies that people view insulin, feeling different from normal, facing complications
CAM as less authoritarian, more empowering and as offering and coming to terms with their own mortality has a
them more personal autonomy and control over their significant effect on the patient’s quality of life; often
healthcare decisions (Astin 1998, Thorne et al. 2002). The engendering fear and powerlessness; and can compromise
findings indicate that people actively engage in the use of physical and psychological functioning (Dunning 2003).
CAM as a strategy for health self-management. Nowadays, Importantly, since providing people with appropriate recom-
diabetes care focuses on self-management with patients and mendations, so they can make informed decisions is a
healthcare professionals collaborating as equals. Therefore, significant aspect of nursing care; nurses need to seek
assisting patients in the assessment of potential benefits, evidence-based information regarding CAM for the manage-
adverse effects and potential interactions of CAMs with ment of diabetes in order to assist people with diabetes to use
conventional medicine, when used concomitantly, is an CAMs safely and to plan a suitable approach to achieve
essential role of healthcare professionals. maximal blood glucose control.

Common types of CAM used by people with diabetes Disclosure of CAM use to healthcare professionals

When examining which CAM are most frequently used by Safety of CAM use is an important issue from the point of
people with diabetes, there are two major kinds of surveys: view of people using these medicines and healthcare profes-
those that include the whole spectrum of CAM and those that sionals, particularly because of the growing popularity of
include only ‘biologically based therapies’. The studies that CAM use among people with diabetes. Although CAM is not
focus only on biologically based CAMs were conducted in presently considered as part of conventional medicine, the
Canada and Australia. They display similar results, for majority of patients use CAM along with conventional
example, the most frequently used biologically based CAM medicine rather than in place of it. Problematically, the
were: vitamins (most frequently used were multivitamins and extent to which people disclose their use of CAM to their
vitamins B and C); nutritional supplements (fish oil, glucosa- physicians actually remains low. However, only four out of
mine and calcium); and herbal medicines (garlic, echinacea the 13 studies included in this review reported on the issue of
and ginkgo) (Ryan et al. 2001, Clifford et al. 2003). The other the disclosure of CAM use to healthcare professionals. In the
surveys included the whole spectrum of CAM therapies used USA, the non-disclosure rate (43%) (Egede et al. 2002) is
in countries such as the USA and Thailand and those most lower than in countries such as Mexico (64%) (Argaez-Lopez
frequently used for diabetes were prayer/spiritual practice, et al. 2003) and Thailand (64Æ4%) (Moolasarn et al. 2005).
herbal medicines, relaxation techniques, chiropractic, nutri- In one qualitative study, conducted by Dunning (2003) in
tional advice and massage (Egede et al. 2002, Moolasarn et al. Australia (see Table 3), only one of 10 participants had
2005, Arcury et al. 2006, Bell et al. 2006). However, countries informed conventional health professionals of CAM use;
with a long tradition of alternative health systems such as however, all participants had informed their CAM therapist
Arabia, Mexico and Korea reported regimens ranging widely that they had diabetes, and detailed the medications they
from plant derived to animal materials, such as fenugreek, were taking. There is an opportunity for nursing staff to
opuntia, and silk worm (Argaez-Lopez et al. 2003, Lee et al. make a difference by taking time in patient assessment and
2004, Moolasarn et al. 2005). This phenomenon may occur displaying an attitude that encourages people to disclose their
because when people choose a particular CAM, they are CAM use.
usually attracted to options congruent with their values, Patients usually expressed the attitude that CAM may not
culture and world view (Vincent & Furnham 1996, Astin help much, but will probably not hurt, provided they
1998, Dunning 2003). All the popular CAM therapies continue with the conventional treatments recommended by
outlined in each study are presented in Tables 2 and 3. their physicians (Hunt et al. 2000). Contrary to this popular

 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd 315
H.-Y. Chang et al.

belief, several case reports indicated that the use of both undertake a complete health assessment, to identify which
herbal medicine and conventional medicine resulted in the CAMs have benefit for people with diabetes and potential
adverse effects from herb–drug interaction (Gill et al. 1994, CAM–drug interactions, and to be able to inform physicians
Dunning et al. 2001, Goudie & Kaye 2001, Wood et al. and other healthcare professionals about their patients’ CAM
2004). For example, Clifford et al. (2003) reported that, of use (Cuellar et al. 2003).
people with diabetes, >43% who used CAM had the The increased presence of CAM-related courses in medical
potential for herb–drug interaction, and required extra and nursing curricula is apparent in the USA and Canada, as
monitoring for the adverse effects. Therefore, a responsible well as other countries (Haramati & Lumpkin 2004);
healthcare approach is that patients should receive evidence- however, most CAM courses in a curriculum are electives
based CAM information about efficacy, effectiveness, adverse (Dutta et al. 2003) and few are offered in the baccalaureate
effects and possible interactions, to inform their decision- level programmes (Burke et al. 2004). Several research studies
making related to CAM use. indicated that the majority of healthcare professionals still
consider their knowledge insufficient to meet current needs
regarding answering their patients’ questions and appro-
Implications for nursing
priately referring them to reputable CAM practitioners
The high levels of CAM use, reported in the studies (DeKeyser et al. 2001, Fearson 2003, Wetzel et al. 2003).
summarized in Tables 2 and 3, highlight the need for an Thus, up-to-date education on CAM within undergraduate
evidence-based assessment of CAM. This is necessary because and postgraduate programmes and ongoing professional
all of these therapies and medicines have their own potential development is imperative. For example, future nursing
benefits and potential interactions with conventional treat- curricula should include content on the efficacy and effect-
ments and should be evaluated for quality, safety and efficacy iveness of CAMs used by people with diabetes, possible toxic
before use. Common herbal medicines used by people with effects and potential interactions with other medicines.
diabetes include ginseng, bitter melon, fenugreek and nutri- In future CAM surveys it is imperative that definitions and
tional supplements such as chromium, magnesium and fish oil methods are employed consistently to enable clinicians and
(Ezzo et al. 2001, Yeh et al. 2003, Manyam 2004). Table 1 researchers to compare results across a number of studies. It
presents an overview of commonly used medicinal herbs and is important for researchers to use the most common
nutritional supplements; however, this list is not a complete definition of CAM and the categories of CAM as defined
review of CAMs used in diabetes. More than 1000 traditional by NCCAM. It would also be helpful if researchers were to
plants have been claimed to benefit treatment of diabetes survey and report separately on CAM therapist consultations
worldwide (Day 2005), but not all of these have been and the use of CAMs, as well as on point prevalence and
thoroughly investigated. Several comprehensive reviews sum- lifetime prevalence of use.
marize the evidence for the use of numerous plants and Most of the studies included in this review did not question
supplements such as fish oil in the treatment of diabetes participants about their reasons for using CAM (Leese et al.
(Farmer et al. 2001, Shane-McWhorter 2001, Yeh et al. 1997, Ryan et al. 2001, Argaez-Lopez et al. 2003, Clifford
2003). CAM therapies commonly used for the treatment of et al. 2003). Ninety-one per cent, however, of participants in
diabetes include traditional Chinese medicine, yoga and Leese et al.’s (1997) study used CAM for non-diabetes-related
massage. However, no recent reviews of the evidence of problems, while only 35% reported use specifically for
some CAM therapies such as acupuncture exist, although diabetes in Yeh et al.’s (2002) study. Future research needs
initial studies suggest beneficial effects, for example in to include questions about reason for use of as well as type of
diabetes related peripheral neuritis (Jiang et al. 2006). CAM used and frequency.
This literature review not only assists nurses and other In order to assist healthcare professionals in the under-
healthcare professionals to understand the prevalence of standing of the culture of diabetes care, future studies might
CAM use among people with diabetes, but also to raise the benefit from using cultural frameworks such as the explan-
issue of non-disclosure of CAM use to healthcare profession- atory model of illness to explore the illness experience and the
als and the resultant potential risks. Nurses need to be aware role of CAM use in coping with chronic illness. While there is
of the possibility that their patients are using CAM therapies; currently some information available about which CAMs are
particularly, as they are often the patient’s first point of used by people with diabetes, further research needs to focus
contact within the healthcare system, and thus may under- on the patterns of use, the predictors of use, the factors
take the first assessment of the patient’s healthcare practices. affecting communication with health professionals and the
Essentially, nurses need knowledge about CAM in order to efficacy and effectiveness of commonly used CAMs.

316  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
JAN: REVIEW PAPER Use of complementary and alternative medicine people with diabetes

professionals. This may cause disease mismanagement when

What is already known about this topic healthcare professionals are unaware of CAM use.
• Diabetes mellitus is a chronic illness, and a leading Therefore, healthcare professionals must be aware of the
cause of death, disability and hospitalization. increase in the number of patients who use CAM while
• Complementary and alternative medicine use varies under conventional care.
from country to country and within different patient Through diabetes patient education programmes, nurses
populations. are the members of healthcare team who work most closely
• Diabetes mellitus affects the entirety of a person’s being with people with diabetes in taking control of their disease,
and increasingly people use complementary and alter- especially in aiming to empower people to self-manage their
native medicine in conjunction with other medical diabetes. However, if nurses do not consider the patient’s
treatments and lifestyle modifications to manage their background, health history, health beliefs and cultural
condition and improve well-being. 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
What this paper adds helping them sort through the many available choices are
• Review of the epidemiological studies related to com- important roles for nurses among other healthcare profes-
plementary and alternative medicine use is complicated sionals. Therefore, understanding CAM therapies and their
by inconsistency of definition and research design. integration into conventional medicine is needed in order to
• Use of complementary and alternative medicine varies ensure patient safety and optimize health care.
among people with diabetes but nutritional supple-
ments, herbal medicines, nutritional advice, spiritual
Author contributions
healing and relaxation techniques are the most popular
therapies in this population. HC, MW and ET were responsible for the study conception
• Because of the risk of interactions between conventional and design and the drafting of the manuscript. HC, MW and
and complementary medicines, healthcare professionals ET made critical revisions to the paper. MW and ET
need to include complementary and alternative medi- supervised the study.
cine use in patient assessment and there may be a need
to increase the focus on their use in nursing curricula.
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