Complementary therapies and diabetes

Trisha Dunning*

Professor Director, Endocrinology and Diabetes Nursing Research, Department of Endocrinology,St. Vincent’s Hospital, 4th Floor, Daly Wing, 41, Victoria Parade, Fitzroy, VIC 3065, Australia andUniversity of Melbourne, Melbourne, Australia

Summary There is increasing recognition that people with diabetes use a range ofcomplementary therapies (CT), for a number of conditions, but do not always informtheir conventional health practitioners about their use. Controlling blood glucoselevels in people with diabetes is important to reduce the consequent metabolicabnormalities and symptoms and the incidence of long-term complications.Conventional medical and nursing practitioners often incorrectly assume that theyare used to control blood glucose levels, e.g. using herbal medicines to increaseinsulin production or reduce insulin resistance. CT can be beneficial for people withdiabetes. They can also lead to adverse events. This paper describes the outcome ofmonitoring complementary therapy use in our diabetic outpatient services in 2001,the results of a focus group (n ¼ 10) to explore issues identified in the monitoringprocess and a survey undertaken with a convenience sample of diabetes educators(n ¼ 40).Twenty percent of patients used CT and there were three adverse events in the

monitoring phase. Eight of the 10 focus group participants used CT and 16 of thediabetes educators used CT in patient care. Only one had a complementary therapyqualification.r 2003 Elsevier Science Ltd. All rights reserved.

KEYWORDS

Diabetes;

Herbs;

Aromatherapy;

Advice

Introduction

Diabetes is a chronic, incurable disease caused bylack of insulin, Type 1, or insulin resistance, Type 2.Both types are associated with short- and long-termcomplications that affect the individual’s quality oflife and often engender fear and powerlessness andcan compromise physical and psychological func-tioning. Since the publication of the findings of theDiabetes Control and Complications Trial in 19931

and the United Kingdom Prospective Diabetes Studyin 1998,2 which demonstrated that good bloodglucose control reduced long-term complications,the emphasis in diabetes management has been on

achieving good metabolic control. However,achieving good control can be difficult for manyindividuals because the delicate hormonal balancethat controls glucose homeostasis is disrupted bythe disease, before diagnosis and is easily upset byphysical and psychological stress after diagnosiseven if the person is on diabetes treatment. Inaddition, Type 2 diabetes is a ‘silent’ disease, thatis, the disease and its complications often occurwithout obvious signs and symptoms, which makesit difficult for people to accept the diagnosis.

Complications such as eye and cardiovasculardisease are frequently present at diagnosis. Con-ventional medicine has effective ways to controlblood glucose but requires significant self-care onthe part of the individual. It is the natural courseof Type 2 diabetes for the majority of individualsto eventually require insulin, even if they areinitially commenced on diet or oral hypoglycaemicagents.

*Present address: Endocrinology and Diabetes Nursing Re-search, Department of Endocrinology, St. Vincent’s Hospital, 4thFloor, Daly Wing, 41, Victoria Parade, Fitzroy, VIC 3065,Australia. Tel.: +61-3-9288-3573; fax: +61-3-9288-3590.E-mail address: dunnint@svhm.org.au (T. Dunning).

1353-6117/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved.doi:10.1016/S1353-6117(02)00143-9

Complementary Therapies in Nursing & Midwifery (2003) 9, 74–80

Because of the potential threat to quality of lifeand the chronic nature of diabetes many peopleturn to complementary therapies (CT) to assistthem to cope and control the disease. That they doso, is not unexpected since many people withchronic diseases utilise CT.3–5 In fact, it could besaid that we are witnessing the evolution of a newhealth paradigm where the current reweaving ofhealing traditions and the interaction of conven-tional and CT is an attempt to address the healthproblems of our time. Not so long ago, the twoapproaches appeared to be distinct, but over thepast 5 years there has been a growing acceptanceof some CT by conventional practitioners and manyincorporate CTs into their practices, refer to CTs orwork with complementary therapists in sharedhealth facilities. Research into CT in conventionalhealth settings and universities is also occurringand supports the dynamic and forward thinkingnature of the Cochrane Collaboration that definedCT as: ‘Therapeutic and diagnostic disciplinesoutside conventional medical practice’.6

The definition goes on to point out that theboundaries within and between complementaryand conventional therapies is not always sharp orfixed. In fact, many of the current boundarychanges are occurring in response to the globalincrease in the use of CTs by the general public,including health professionals, who use them fortheir personal health care. A number of studieshave shown that the types of people most likely touse CT are:

* In poor health.* Have a chronic disease such as diabetes.* Well educated women who are financially well

off.* Interested in self-care and want to be involved in

their health care.* Culturally and/or philosophically attuned to CT.* People who have experienced a traumatic life

event. The diagnosis of diabetes is viewed bysome people as a traumatic experience becauseof the associated complications, its incurablenature and the need for lifelong self-care andcoping.7

However, the pathway to complementary care iscomplex and nonlinear.8 People base their healthchoices on their existing knowledge, beliefs, pre-vious experiences and the advice of significantothers, including health professionals. The time ofdiagnosis is a stressful period and the informationreceived prior to diagnosis influences the person’sperceptions of the disease, which in turn affectsself-care and recovery.9 People frequently usemore than one CT and combine CT with conven-

tional therapies. This means that, in many cases,people self-diagnose and self-treat and may, there-fore, delay seeking appropriate, timely advice andmanagement. Some people become disenchantedwith conventional medicine or conventional healthpractitioners and seek alternative sources of carethat are congruent with their health and philoso-phies.

Complementary therapy philosophy

Complementary therapy philosophy focuses on theindividual and achieving balance and harmony toassist the body to heal itself8 and considers thepatient to be an active participant in their care,which is congruent with current diabetes educationcare models that focus on patient empowermentand patient-centred care, where the individual’shealth goals, rather than the health professional’sgoals, are given priority.10 Many complementarytherapists see illness as both a threat and anopportunity. This disease duality is also true ofdiabetes, especially Type 2 diabetes, where life-style changes can result in better diabetes balanceand improved health (the opportunity), and delaythe need for medications and complications (thethreat).

How frequently do people with diabetesuse CT?

Studies that examine complementary therapyusage rates by people with diabetes are relativelyrecent and often have a negative tone towards CT.Leese et al.11 surveyed people with diabetesattending a diabetic outpatient clinic in the UKand found 17% were using CT. A similar survey inCanada found 25% of people with diabetes usedCT.12 More recently, a nation-wide survey in theUSA found people with diabetes were 1.6 timesmore likely to use CT than nondiabetics, but thepattern of use was similar in both groups.13 Themain therapies used were nutritional and spiritualtherapies, herbs, massage and meditation. Olderpeople with a good income were the group mostlikely to use CT in Egede’s survey.

Contrary to the popular belief that people whouse CT do not discuss its use with their doctors, 57%reported discussing their CT use with their doctorsand 43% were referred by doctors, to a comple-mentary therapist. These figures could reflect thegrowing knowledge about, and acceptance of, CTby conventional practitioners and willingness to

Complementary therapies and diabetes 75

collaborative with complementary therapy practi-tioners. Alternatively, it might indicate that peopleare taking responsibility for their health, demand-ing a say in their care and finding and tryingoptions. It also reflects the fact that healthprofessionals are dealing with an increasinglywell-informed public.

Complementary therapy usage was monitored inour diabetic outpatient service during 2001. Theresults indicate that >25% used CT. At the sametime, adverse events associated with complemen-tary therapy use were monitored. Only three wererecorded:

* Hypoglycaemia from combining a traditionalChinese herbal preparation with oral hypogly-caemia agents.14

* Hyperglycaemia following the initiation of Spir-ulina, largely due to the preparation containingiodine that changed the man’s thyroid functionand led to hyperglycaemia. The hyperglycaemiaresolved when the Spirulina was stopped.

* Infected foot burns requiring hospitalisation andintravenous antibiotics from taking hot bathsfollowing a media release stating that hot bathscould lower blood glucose levels.

Our clinic is situated in an inner city universityteaching hospital with a large population of non-English-speaking patients, many have little formalschooling and few have higher education qualifica-tions. Although there are policies for using CT in thehospital it is not actively encouraged. Vapourisingessential oils occurs in many clinical areas but it isnot used with any defined clinical intent andoutcomes are not monitored. The physiotherapydepartment organises Feldenkrais training sessionseach year and some nurses have CT qualifications,particularly in aromatherapy, massage and kinesiol-ogy.

A number of adverse events in people withdiabetes associated with using CT have beenrecorded in the literature. They include:

* Stopping insulin in a person with Type 1 diabetesleading to ketoacidosis and admission to hospi-tal.15

* Hypoglycaemia from contaminated herbal med-ications.16

* Trauma and burns from moxibustion and cuppingto insensitive neuropathic legs.17

* Bruising from an aromatherapy massage in apatient on anticoagulent therapy. The man’swife gave the massage. It is not known if theessential oils were responsible for the bruising orwhether the pressure from the massage caused

it. Alternatively, it may have been a coincidentalfinding.

These adverse events raise questions about theknowledge of people with diabetes, and the healthprofessionals who care for them, about the safe useof CT and the safety and efficiency of using CT inthe management of people with diabetes.

A number of benefits for people with diabetesfrom using CT have also been reported. Theseinclude improved blood glucose control in childrenreceiving regular massage and reduced stress intheir parents18 and improving self-esteem, accep-tance of diabetes and learning and informationrecall.19

Aims of the study

With that background a study was designed thataimed to:

* Explore the reasons why people with diabetesattending our outpatient clinics use CT.

* Determine the type of therapies they are mostlikely to use.

* Use the information obtained to develop advicefor people with diabetes and health profes-sionals about the safe use of CT.

Methods

Two groups were surveyed. A focus group ofpatients to enable the issues that emerged in the12 months monitoring program to be explored anddescribed, and a self-complete anonymous ques-tionnaire was administered to a conveniencesample of diabetes educators.

Focus group

The focus group consisted of people with diabetesrecruited by placing advertisements in the DiabetesCentre and Diabetes Outpatient Clinics. The re-searcher guided the focus group the discussion, andthe researcher and two independent observersrecorded the discussion. The discussion was nottaped because previous experience of focus groupsin the same population found that the taperecorder inhibited discussion. The three transcriptswere analysed separately to identify the emergingthemes. The three analyses were compared and86% congruence was obtained.

76 T. Dunning

Survey of diabetes educators

A group of diabetes educators attending a profes-sional development seminar about a new diabetesproduct were invited to complete an anonymousquestionnaire, 38 of the 40 attendees participated.A combination of fixed and open questions wasused. The questionnaires were not formally vali-dated prior to the study but a panel of expertsestablished face and content validity.

Results

Focus group (n=10)

Seven women and three men participated, theirages ranged from 28 to 62 years, mean 57 years.Eight of the 10 regularly used CT to reduce stressand improve their mood, in skin care, including footcare, general well-being, analgesia and nondia-betes-related reasons such as arthritis and beautycare. Only one was using a complementary therapy,Chinese herbs, to control blood glucose. Allparticipants were satisfied with the therapies theywere using, did not believe there were anyunwanted interactions with their conventionalmedicines and intended to continue using the CT.The therapies they used are shown in Table 1.

None of the participants had stopped, or altered,their conventional medications. All participantshad informed their complementary therapists thatthey had diabetes and the medications they weretaking. Only one told their conventional carers theywere using CT. All eight believed they consultedreputable, appropriately qualified complementarytherapists. The ways these therapists were identi-fied are shown in Table 2.

Diabetes educator survey (n ¼ 38)

Sixteen of the 38 respondents stated that they usedCT in the management of their patients with

diabetes and 27 used CT personally. Only onerespondent had a complementary therapy qualifi-cation (at certificate level), a further four hadattended short complementary therapy workshopsor seminars. The diabetes educators used CT forthemselves to reduce stress and in beauty care andone to manage chronic back pain.

They used the therapies in patient care tomanage stress, relieve pain and improve well-being. The effectiveness of CT to achieve thesegoals was not monitored, but five respondents citedreductions in HbA1c, representing improved bloodglucose control, and reduced doses of diabeticmedications as a result of their patients using CT.No adverse events associated with using CT forthemselves or in patient care were reported.

Discussion

The range of therapies used by our patients and thediabetes educators was similar to other studies.Interestingly, only one patient used CT with aprimary aim of reducing their blood glucose levels.This lady used an herb that has some evidence tosupport its blood glucose lowering reduction effect.However, stress reduction, pain management andimproved well-being reported by other patients allhave secondary benefits for blood glucose controlby reducing the counter regulatory hormone re-sponse and reducing insulin resistance.

The high level of use of CT for reasons other thanblood glucose control, clearly shows the impor-tance of establishing why people with diabetes useCTwhen deciding if they are effective and whethermanagement goals have been met. Many diabeteshealth professionals assume, that because theperson has diabetes and chooses to use a comple-mentary therapy, it must be to control bloodglucose. This was clearly not the case for themajority of our subjects and highlights the im-portance of considering well-being and quality oflife as well as metabolic parameters when devel-oping health plans for people with diabetes.

Table 1 CT used by people with diabetes attend-ing the diabetic outpatient clinic January–Decem-ber 2001, shown in alphabetical order.

Aromatherapy and/or massageHerbal medicinesMassageMeditationNaturopathyNutritional therapies and supplementsTraditional Chinese medicine

Table 2 How complementary therapists wereidentified.

Recommendation of a friendF6Advertisement in a magazineF1Professional practitioner list in complementarytherapy journalsF1Complementary therapy consumer organisationF1Telephoning a complementary therapy college for arecommendationF1

Complementary therapies and diabetes 77

Patients used a range of strategies to identifyappropriate complementary therapists. The majorityof methods used had an element of ‘recommenda-tion’ by a significant person or authority. This findinghighlights the importance of significant others andauthority figures in patients’ decision-making pro-cesses and health behaviours, and the need forhealth professionals to be aware of the impact oftheir beliefs and attitudes on the beliefs andattitudes of their patients. In particular, healthprofessionals should only offer advice about CT whenthey have the knowledge and competence to do so,as they would with any other area of practice.

It is a concern that only one of the 16 diabeteseducators who used CT in patient care had aqualification and four considered that a short-course seminar, or workshop gave them sufficientknowledge and skills to use CT therapeutically.There is a growing awareness of the need foradequate practitioner qualifications and compe-tence, and of the complexity of most CT. Comple-mentary therapy modules and short courses areincreasingly being incorporated into undergraduatenursing and medical training and a range of post-graduate forums are offered on a regular basis.They are not intended to prepare nurses anddoctors to utilise particular CTs in practice and donot confer CT qualifications20.

It is interesting that all patients using CT in ourstudy had informed their complementary therapiststhat they had diabetes and about their conven-tional care, but only one informed their conven-tional health professionals that they were using CT.Despite the wider acceptance of CT, many conven-tional health practitioners still view CT withscepticism and communicate these attitudes,either directly or indirectly to their patients. It isunlikely that patients would discuss complemen-tary therapy use under these circumstances.Similarly, not telling, may not be deliberate with-holding of information, rather it may not seemrelevant to some patients to tell their diabetespractitioners about their CT use, especially if theyare not using them for their diabetes management.It is not yet standard practice to ask aboutcomplementary therapy use in routine history andassessment.

Conventional practitioners need to be sensitiveto the cultural, philosophical and health choices ofindividuals, respect their choices and recognisethat complementary therapy use often indicates amotivated person interested in their health care.The focus of any care plan should be on what workssafely and effectively to achieve diabetes balance.Taking pressure off the need for ‘control’ andplacing the emphasis on ‘balance’ might be more

effective and many CT can help achieve thatbalance.

Clinical parameters and diabetes managementcontrol were not measured as part of this study,however, the diabetes educators reported im-proved metabolic control in people using CT. It isnot possible to say with certainty that theimprovement was a result of using CT, particularlyas outcomes were not monitored and the treatmenteffects reported were different from the partici-pant’s stated reasons for using CT.

No adverse events such as those outlined in theintroduction were observed or reported by eitherthe patient or the diabetes educator study groups.However, the potential for adverse events to occurwas present in the person using Chinese herbs,especially if they were also taking oral hypogly-caemic agents or insulin, and in the use of CT byuntrained health professionals. The need to adjustconventional medications and/or CT could arise ifblood glucose levels improve. The lack of objectiveoutcome monitoring reduces the value of thesereported improvements in metabolic control.

The time of diagnosis of diabetes is stressful. CTcan be used to reduce stress and help the personaccept diabetes fit it into the framework of theirlives. Reducing stress has secondary benefits formetabolic control. Improved self-esteem, well-being and quality of life are important managementconsiderations where CT can have a role. Sometherapies, especially herbal medicines, directlyreduce blood glucose and blood fats and therapies,such as aromatherapy, can be used in education andcounselling to help the individual link new informa-tion into their existing knowledge base (classicalconditioning).

Limitations of the study

Both the focus group and the diabetes educatorgroup represent only a small proportion of therespective sampling populations and their viewsmay not be representative of other patients ordiabetes educators. Therefore, care should betaken when generalising the results to otherpopulations. People in the focus group may haveself-selected into the group on the basis that theywere using CT, and their views, as expressed in thefocus group may not represent the views of otherpatients attending the diabetes service. However,since the aim was to explore the reasons people useCTand the types of therapies they are likely to use,not to make generalisations, self-selection wasseen as a benefit of the study.

78 T. Dunning

Conclusions and implications for diabetescare

The people with diabetes in our study used a rangeof complementary therapies (CT) for a number ofreasons, primarily to manage stress, the unpleasantsymptoms of diabetes and/or concomitant diseasesand skin care. They believed CT confer healthbenefits and improved their quality of life. Most did

not disclose complementary therapy use to theirconventional carers.

The patient’s desired outcomes for complemen-tary therapy use, differed from their outcomesassumed by health professionals, and patientsperceive the benefits of CT differently from healthprofessionals. They used a range of therapies anddid not cease their conventional treatment, whichmeans they often used complementary and con-ventional therapies together. The combination can

Table 3 Suggested advice for patients about the safe use of complementary therapies.

Decide on the health goals you want to achieve.Select a therapy or therapies that is/are likely to achieve these goals.Learn all there is about the therapies so you can use it from an informed perspective.Consult reputable practitioners.Buy products from reputable sources that are correctly labelled and stored.Have a correct diagnosis before using any therapy.Inform conventional and complementary practitioners that you see for health care about all the therapies you areusing.Monitor the effects against the health goals you set. Consider the positive and negative effects and discuss themwith your complementary and conventional practitioners.Be aware that some complementary therapies may take some time before any effect is noticed.Some complementary therapies, e.g. essential oils should not be used continuously for long periods.Complementary therapy doses, e.g. herbal medicines, may need to be adjusted for surgery, illness,investigations, changes in conventional therapy.

Name of the product, sometimes a picture is also used

HERBAL PRODUCT X

Relaxes and soothes Muscular aches & pains

Each tablet contains…..

Dose….. Directions for use…..

Aust L number or Aust R Expiry date

Store

Manufactured by…..

Made in Australia

Tells you how tostore the product

Tells you who makes the product

Tells you the countrywhere the product was made

Claims and indications for use as entered on the Australian Register of Therapeutic Goods

(TGA).

Tells you the contents of each tablet, capsule or liquid. If it is a herbal product, the parts of the plant used and the quantityof raw material usedexpressed as equivalent dryor fresh weight should be shown.

Tells you how much ofthe product to take eachday.

Tells you how to take thepreparation, how often to take it and how long it acts for, for specific ages and medical conditions. Allergies and other warning statements (if needed)

Aust L denotes the product wasreviewed for quality and safetybefore being authorised by theTGA for use as a listed product.Aust R means the product isTGA registered and has undergone testing for qualitysafety and efficiency.

Expirydate

Fig. 1 Basic information that should be on herbal and aromatherapy products, based on Kron, 2002.21

Complementary therapies and diabetes 79

result in unwanted side effects if both therapies arenot monitored and the person is not given appro-priate advice about all their treatment options sothey can make informed decisions about thetherapies they use.

The combination of complementary and conven-tional therapies or of different CT can also meanthat reduced doses of conventional medicines canbe used. In addition, CT can confer health benefitsthat lead to improved metabolic control either, as adirect effect of the therapy or as a secondarybenefit through effective stress management.Table 3 suggests some advice about CT use thatcan be given to people with diabetes and Fig. 1 isan example of important information that shouldbe included on a complementary therapy productlabel that could be given to patients. Finally, I saywe ought not to reject the ancient art as if it were,and had not been properly founded, since it did notattain accuracy in all things, but rather revive itand admire its discoveries.

Hippocrates, On Ancient Medicine

References

1. Diabetes Control and Complications Trial Research Group.The effect of intensive insulin treatment of diabetes on thedevelopment, progression of long term complications ininsulin dependent diabetes mellitus. N Engl J Med 1993;329:977–86.

2. United Kingdom Prospective Diabetes Study (UKPDS). Gly-caemia. Lancet 1998;352:837–53.

3. Lloyd P, Lupton D, Wiesner D, Hasleton S. Choosingalternative therapy: an Australian study of sociodemo-graphic characteristics and motives of patients resident inSydney. Australas J Public Health 1993;7(2):135–44.

4. MacLennan A, Wilson P, Taylor A. Prevalence and cost ofalternative medicines in Australia. Lancet 1996;347:569–73.

5. Hunter A. Why do people see natural therapists? A review ofthe surveys. Diversity 1997;10:15–9.

6. Cochrane Collaboration. Complementary therapy healthfield, 1993.

7. Dunning P, Martin M. Using a focus group to explore perceptionsof diabetic severity. Pract Diabetes Int 1997;14(7):185–8.

8. Vincent C, Furnham A. Complementary medicineFa re-search approach. New York: Wiley, 1997.

9. Descombe M. Personal health and the social psychology ofrisk taking. Health Educ Res 1993;8(4):505–17.

10. Anderson R, Funnell M, Arnold M. Using the empowermentapproach to help patients change behaviour. In: Anderson B,Rubin R, editors. Practical psychology for clinicians.Alexandria: American Diabetes Association, 1996. p. 163–72.

11. Leese G, Gill G, Houghton G. Prevalence of complementarymedicine usage within a diabetic clinic. Pract Diabetes Int1997;14(7):207–8.

12. Ryan E, Pick M, Marceau C. Use of alternative therapies indiabetes mellitus. Proceedings of the American DiabetesAssociation Conference, San Diego, USA, 1999.

13. Egede L, Xiaobou Y, Zheng D, Silverstein M. The prevalence andpattern of complementary and alternative medicine use inindividuals with diabetes. Diabetes Care 2002;25:324–9.

14. Dunning T, Chan S, Pendek R, Motid M, Ward G. A cautionarytale of the use of complementary therapies. DiabetesPrimary Care 2001;3(2):59–63.

15. Gill G, Redmond S, Garratt F, Paisley R. Diabetes and alternativemedicine: cause for concern. Diabetic Med 1994;11:210–3.

16. Goudie A, Kayes. Contaminated medication precipitatinghypoglycaemia. Med J Aust 2001;175:256–57.

17. Ewins D, Bakker K, Youn M, Boulton A. Alternative medicine:potential dangers for the diabetic foot. Diabetic Med1993;10:988–92.

18. Field T, Hernandez-reif M, La Greca A, Shaw K, Schenberg K,Kuhn C. Massage therapy lowers blood glucose levels inchildren with diabetes. Diabetes Spectrum 1997;10:237–9.

19. Dunning T. Complementary therapies. Diabetes Voice2002;14(2):10–3.

20. Hunter A. Natural therapies trainingFhow good is it?Diversity 2002;2(7):40–7.

21. Kron J. Herbalism. Complementary Med 2002;1(2):27–31.

Leisure by William Henry Davies (1871-1940)

What is this life if, full of care,We have no time to stand and stare.

No time to stand beneath the boughsAnd stare as long as sheep or cows.

No time to see, when woods we pass,Where squirrels hide their nuts in grass.

No time to see, in broad daylight,Streams full of stars, like skies at night.

No time to turn at Beauty’s glance,And watch her feet, how they can dance.

No time to wait ‘til her mouth canEnrich that smile her eyes began.

A poor life this if, full of care,We have no time to stand and stare.

80 T. Dunning