Complementary and Alternative Medicine Use With Diabetes
by Leonard E. Egede, M.D., MS
| Geriatric Times |
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May/June 2004 |
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Vol. V |
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Issue 3 |
The National Center for Complementary and Alternative Medicine (NCCAM) defines complementary and alternative medicine (CAM) as "a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine" (NCCAM, 2002). Three key terms in the CAM literature need clarification. The term complementary implies that these types of therapies are used in conjunction with conventional medicine, whereas the term alternative implies that the therapy is used in lieu of conventional medicine. Integrative medicine, on the other hand, is a combination of mainstream medical treatment and CAM therapies that are offered to patients.
Five categories of CAM therapies have been classified (NCCAM, 2002) and can be found in Table 1.
History of CAM Use in the United States
Data suggest that an increasing number of people in the United States use one or more CAM remedies, and these remedies appear to be used most frequently to treat chronic medical conditions (Eisenberg et al., 1993). Although CAM therapies appear to be used predominantly as complements to conventional treatments, people who use both CAM and conventional treatments tend to have significantly more outpatient physician visits (Druss and Rosenheck, 1999). The costs associated with CAM use in the United States increased by approximately 45% between 1990 and 1997 (Eisenberg et al., 1998). Approximately $21.2 billion was spent on CAM in 1997, of which $12.2 billion was attributed to out-of-pocket expenses. Certain types of patients appear more likely to use CAM remedies: whites, more educated individuals (higher than high school education) and people living in the western United States (McFarland et al., 2002).
CAM for the Treatment of Diabetes
A tremendous number of CAM treatments are recommended for diabetes, and most of these agents are touted as having hypoglycemic effects. For instance, chromium picolinate (Fox and Sabovic, 1998), stress management with biofeedback (McGrady et al., 1991) and relaxation training (Lane et al., 1993), acupuncture (Chen, 1987; Chen et al., 1994), and traditional Chinese remedies (Zhang and Teng, 1986) have been reported to possibly be of benefit to people with diabetes. Table 2 classifies the long list of agents that are purported have hypoglycemic effects in to the five NCCAM categories. It is noteworthy that the efficacy of most CAM therapies for glucose control and diabetes management is unproved. In fact, conflicting reports in the literature about the benefits of CAM therapies and reports of adverse outcomes from the use of CAM in people with diabetes raise several concerns (Ernst, 2001).
A major concern is that people with diabetes may use these CAM agents in place of clinically proven conventional diabetes treatments. Another concern is the potential for drug interactions when these agents are used as complements to conventional treatments. Finally, there is concern that some of these agents may worsen glycemic control or even create additional complications for people with diabetes.
Leg ulcers have been reported with the use of the traditional Chinese remedy of moxibustion (Ewins et al., 1993), and lead poisoning has been reported due to traditional Indian remedies for diabetes (Keen et al., 1994). Other therapeutic approaches such as prayer, faith healing, unusual diets, and supplements of vitamins and trace elements have resulted in life-threatening ketoacidosis (Gill et al., 1994). Additionally, a review of a host of natural products concluded that claims about their hypoglycemic effects lacked scientific merit and that they could be harmful if used in place of conventional diabetes treatments (Gori and Campbell, 1998). As a result of these concerns, the American Diabetes Association (ADA) continues to caution people with diabetes about using unproven treatments in its annual clinical practice recommendations (ADA, 2003).
The ADA defines a safe and efficacious therapeutic modality as one approved by the U.S. Food and Drug Administration; supported by data in at least two independent, well-controlled, peer-reviewed studies; or endorsed by the ADA's Professional Practice Committee or a relevant medical specialty organization (ADA, 2003). Few of the agents listed in Table 2 meet the ADA definition of safe and efficacious treatments. However, recent research indicates that some CAM agents may have promise as therapeutic adjuncts in the treatment of diabetes. Table 3 lists CAM therapies that are supported by fair-to-good evidence as being beneficial adjunctive treatments for diabetes (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], 1999).
Biofeedback is effective for stress reduction (Lane et al., 1993; McGrady et al., 1991), and acupuncture delivered by experienced practitioners is effective for controlling the chronic pain of peripheral neuropathy associated with diabetes (Abuaisha et al., 1998). Chromium (Althuis et al., 2002), vanadium (Evans and Krentz, 1999; Goldfine et al., 2000) and magnesium (Kao et al., 1999; Lima Mde et al., 1998) are promising agents; however, additional evidence from large, well-designed clinical trials on their efficacy are needed before they can be recommended for use in routine clinical practice. Meditation; prayer; massage therapy; yoga; and art, music and dance therapies may benefit some individuals with diabetes (Andrews, 2002; Rice, 2001) as long as they are used in conjunction with conventional treatments.
CAM Use in Individuals With Diabetes
Only two nationally representative surveys have examined the patterns of CAM use in people with diabetes. The estimates of CAM use ranged from 8% in one study (Egede et al., 2002) to 57% in the other study (Yeh et al., 2002). Clearly, these estimates are broad and likely reflect the manner in which CAM was defined and whether or not the definition of CAM use was associated with a provider visit. When CAM use was linked to a CAM provider visit, only 8% of people with diabetes reported using some form of CAM (Egede et al., 2002), whereas 35% to 57% reported CAM use when it was not linked to a CAM provider visit (Yeh et al., 2002).
Of the reported CAM therapies used among individuals with diabetes, nutritional advice from a non-health care provider was the most frequently used. Among those who reported using CAM for diabetes, the therapies were used to complement conventional diabetes treatments rather than to replace them, and most users informed their physicians about CAM use. The clergy and spiritualists were the most frequently visited CAM providers. On average, CAM users with diabetes made nine visits per year to CAM providers and spent over $400 per year on CAM remedies.
Factors Associated With CAM Use for Diabetes
Among people with diabetes, the factors that predicted CAM use were similar to predictive factors for the general population. Older individuals (greater than or equal to 65 years) and more educated people (more than high school education) seemed more likely to visit CAM providers and use CAM remedies than other individuals with diabetes (Egede et al., 2002). It is unclear why there is a higher likelihood of CAM use in these groups of patients. It may be that older age and higher educational attainment are surrogates for higher earning power, which is needed to pay for the out-of-pocket expenses associated with CAM use.
Approaches to CAM Use in Clinical Practice
Based on evidence suggesting high use of CAM by people with chronic medical conditions, it is clear that physicians will increasingly be inundated with requests for advice on CAM use, referral to CAM providers and questions about combining CAM treatments with conventional diabetes treatments. It will be important for physicians and other health care providers to realize that individuals with diabetes mostly use CAM as a complement to conventional treatment. As a result, health care providers should acquaint themselves with common CAM treatments for diabetes, their mechanisms of action and their likely side effects.
It is also essential that health care providers adopt an open and non-judgmental approach to these discussions. Patients should be routinely asked about the use of CAM, and they should be given ample opportunity to discuss why they use CAM remedies, how often they use them and their beliefs about the role of CAM in diabetes management. Health care providers should devote time when appropriate to explain the FDA's drug approval process--specifically, the meaning of randomized, double-blind, placebo-controlled drug trials and how such rigorous research techniques guide FDA approval of conventional treatments. In addition, patients should be encouraged to read reliable information on CAM treatments such as those available from the NCCAM Web site at <www.nccam.nih.gov>.
Such candid discussions in many cases may prompt patients to discontinue unproven therapies. However, there needs to be willingness on the part of the health care provider to respect and concede to the wishes of the patient if there are no apparent adverse effects of the specific CAM remedy. For instance, it may be appropriate for a health care provider to compromise on the use of meditation, prayer, yoga, dance or music therapies, which have no overt adverse effects, and discourage the use of unproven herbal medicines. In general, discussions about CAM use should be guided by mutual trust and candor.
Dr. Egede is assistant professor of medicine and clinical investigator at the Center for Health Care Research at the Medical University of South Carolina. He has a faculty development fellowship in health services research from MUSC.
References
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