Complete Nurse's Guide to Diabetes Care, 3rd Edition

Chapter 22:

Complementary and Alternative Approaches*

Diana W. Guthrie, PhD, APRN, BC-ADM, CDE, AC-HN,CHTP, FAAN, FAADE,¹ and Laura Shane-McWhorter, PharmD, BCPS, BC-ADM, CDE, FASCP, FAADE²

*The American Diabetes Association does not recommend the use of complementary or alternative medicine in their Standards of Medical Care in Diabetes. The content provided in this chapter is for information purposes only, and does not represent endorsement by the American Diabetes Association. “There continues to be no clear evidence of benefit from herbal or nonherbal (i.e., vitamin or mineral) supplementation for people with diabetes without underlying deficiencies . . . Routine supplemtation with antioxidants, such as vitamin E and C and carotene, is not advised because of lack of evidence of efficacy and concern related to long-term safety.” Standards of Medical Care in Diabetes—2017, Diabetes Care, Volume 40, Supplement 1, January 2017, page S37.

¹Guthrie is a diabetes nurse specialist and practitioner at Mid-America Diabetes Associates, Wichita, KS, and is professor emeritus, the University of Kansas School Medicine, Wichita, KS. ²Shane-McWhorter is a professor (clinical) at the University of Utah College of Pharmacy. She is a board certified pharmacotherapy specialist and teaches pharmacotherapy classes in diabetes, psychiatry, and herbal therapies.

Complementary and alternative medicine (CAM) has existed throughout time. Practitioners and patients have used CAM to treat diabetes for thousands of years. An early Greek treatise, which described diabetes as a “melting down” into the urine, stated that diabetes was treated with fasting, specific food choices, water restriction, or herbs.

People have tried numerous remedies or treatments for various ailments, some with success and some without benefit. CAM therapy, as it is commonly known, and in combination with mainstream medicine, has increased in popularity for a variety of reasons, but a major reason is that consumers believe in the benefits derived from these therapies and in the emerging evidence that the perceived well-being is meaningful.¹ The National Center for Complementary and Alternative Medicine (NCCAM) is officially devoted to the study of CAM treatments. NCCAM is an agency in the U.S. Department of Health and Human Services dedicated to helping define the usefulness and safety of complementary therapies through rigorous scientific research.¹

Two landmark papers have highlighted the public’s interest in using alternative treatment. A benchmark article by Eisenberg et al.² titled “Unconventional Medicine in the United States” (1993) was followed 5 years later by another publication from the same group that focused on changes in the use and opinions of CAM over time.³

When used alongside standard practice, therapies such as energy therapies, massage, and acupuncture, as well as various herbs and supplements, including vitamins or minerals, are considered complementary therapy. These therapies also might include some of the more familiar medical nutrition therapies, exercise, and relaxation techniques. Using these treatments in place of standard practice, particularly medications, is considered alternative therapy. Meal planning and exercise can be considered an alternative form of medicine and was found to be more effective than medication in the prevention of type 2 diabetes (T2D) in the Diabetes Prevention Program.^4,5 In that study, appropriate food choices and exercise were used successfully in place of medication in prediabetes, the earliest form of T2D.

The trend toward more widespread use of CAM therapies has resulted in schools of medicine, nursing, and pharmacy including these treatments in their curricula as required or elective courses. Some programs combine CAM with traditional care, and even some provide credentials for practitioners.^5,6

CATEGORIES OF CAM

NCCAM defines “complementary therapies” as “nonmainstream” approaches used in combination with conventional medicine whereas “alternative therapies” are defined as approaches that replace conventional medicine with nonmainstream therapies.¹ The most recent terminology that NCCAM has used to describe CAM is “complementary health approaches.”¹ Although NCCAM previously divided CAM into five different categories, the agency now identifies two basic subgroups: 1) natural products and 2) mind and body practices.¹ Natural products include botanicals (including herbs), vitamins and minerals, and probiotics, although probiotics and the microbiota of the body is of increasing interest in mainstream medicine. Mind and body practices include a diverse array of procedures or techniques delivered by a trained practitioner. Some examples include acupuncture, healing touch and hypnotherapy, massage therapy, meditation, movement therapies, relaxation techniques, spinal manipulation, the traditional Chinese medicine therapies (including tai chi and qi gong), and yoga (see Table 22.1 for a complete list). Each of these therapeutic areas may directly or indirectly have an effect on diabetes, diabetes-related comorbidities, or its complications. Table 22.2 shows the 10 most common complementary health approaches among adults using CAM.

Table 22.1—NCCAM Therapy Categories

1. Alternative medical systems: Chinese medicine, Ayurveda

2. Mind-body interventions: prayer, meditation, music, support groups

3. Biologically based therapies: dietary supplements, herbal products

4. Manipulative and body-based methods: chiropractic, massage

5. Energy therapies: yoga, healing touch

a. Biofield therapies: qi gong, Reiki, therapeutic touch

b. Bioelectromagnetic-based therapies: electromagnetic fields, alternating or direct current fields

Table 22.2—Ten Most Common Complementary Health Approaches Among Adults—2012⁷

*Dietary supplements other than vitamins and minerals.

Source: Clarke TC, Black LI, Barnes PM, Nahin AL, Trends in the use of of complementary health approaches among adults, United States 2002–2012. Nation Health Statistics Reports, No.79. Hyattsville, MD. National Health Center for Health Statistics. 2015

Table 22.3 describes some common types of mind and body practices included in complementary health approaches. As with conventional medical treatments, no single approach is appropriate for every patient. Treatment should begin with an individualized assessment. For example, CAM could be used to support a person with diabetes who is in pain and thus may be experiencing elevated blood glucose. Any treatment that reduces pain, such as standard medication, or a complementary health approach such as acupuncture, also possibly could lower blood glucose levels. To treat this patient, the practitioner may consider massage therapies, possibly accompanied by a botanical used in aromatherapy. Potentially, this approach may alleviate pain and possibly lower glucose.

Table 22.3—Common Mind and Body Practices

Some CAM types	Description
Acupuncture	Insertion of very fine needles into or along various pathways called meridians.
Acupressure therapy	Using the same points as in acupuncture, but applying pressure to relieve pain to various associated areas of the body.
Aromatherapy	The use of various oils to aid in, depending on the oil, antibacterial action, antiviral action, mood harmonization, relaxation, joint and muscle improvement, and diuretic action, among others.
Art therapy	For the outward expression of inner thoughts and feelings using paints, pencils, markers, and other such media.
Autogenic training	Focuses on various parts of the body while saying to oneself, for example, my arm is heavy and warm.
Ayurveda	Traditional Indian medicine from northern India. Its name translates to the “science of life.” It relates to the three doshas, Vata (wind: air, space); Pita (bile: fire, water); Kapha (phlegm: earth, water), that differentiate various types of individuals and their more specific needs.
Biofeedback	Any type of information that claims to enhance the learning process and support healing—for example, body temperature, an indicator of relaxation and improved blood circulation.
Chiropractic therapy	Licensed for both diagnosis and treatment limited by procedures, based on the premise that much disease is based on pressure on various nerves as they leave the spinal column (spinal misalignment).
Cranialsacral therapy	Involves the movement, through the use of gentle manipulation, of the cranial to the sacral bones of the body.
Guided imagery	This process involves listening and following the directions of thought pronounced by the speaker.
Healing touch	A variety of techniques that claim to increase the body’s energy output or modulate this energy into more useful patterns.
Homeopathic therapy	Defined as another form of energy therapy by NCCAM, derived from substances that come from plants, minerals, or animals, so diluted that no molecules of the original substance remain.
Hypnotherapy	A technique for self-learning to assist in peace of mind and of body through the use of suggestion.
Laughter	Increases pulse rate and respiratory rate, and releases hormones that may aide in decreasing mild depression.
Light therapy	In sunlight or indoors, in the presence of ultraviolet B, to receive the photoactivation of vitamin D on the skin.
Magnetic therapy	The use of magnetic energy in an attempt to alter the body’s responses.
Massage	Manipulation of the muscles, joints, and, indirectly, the nerves to promote healing; various forms of massage use body meridians (shiatsu), a particular pattern of massage (Swedish), or a greater focus on the joints and muscles attached to such joints (Thai).
Music therapy	The use of music for relaxation.8
Naturopathic medicine	An approach based on the “healing power of nature.” Emphasis is placed on nutrition along with body movement, correct breathing, mental attitude, and balance in the “principles of living,” which may include “curative” baths (hydrotherapy).
Neuromuscular therapy	Form of deep tissue massage in which digital pressure and friction are used to release areas of the soft tissues of an area of that body that is experiencing discomfort, especially chronic pain.
Osteopathic therapy	These physicians take the same medical exam as medical doctors. Their approach emphasizes body manipulation practices.
Prayer	Thinking or speaking words that portray feelings, needs, or desires (such as intercessory prayer for the healing or concerns of another) to a higher power.
Progressing relaxation	Focuses on muscle groups, often starting from the toes upward, accompanied with a sense of contraction versus a sense of relaxation.
Qi gong	Qi (flow of air, vital energy) and gong (perseverant practice) involves movement, breathing practices, and conscious control of body energy. Some forms also include nutrition and the way of eating.
Reflexology	Massage and manipulation of the reflexes of the feet (or hands) for the purpose of “rebalancing” the body.
Reiki	Supporting the flow of energy throughout the body for the purpose of healing.
Rolfing	A program of structural integration through manipulation, usually over 10 sessions designed to integrate the entire myofascial system of the body.
Shiatsu	Or “finger pressure,” which usually involves pressure on specific meridians, and may include acupuncture, and aroma therapy to release the chi or energy.
South American spiritism	Spiritual healers collaborating, in other countries, with licensed physicians focusing on the cause and effect of disease as a form of energy transference (curanderos often may be asked for advice before or with medical treatment; shamans may be involved for spiritual direction and treatment).
Southern African healing	Illness is believed to be associated with psychological conflicts with people alive or dead. Traditional healers have various practices to drive out these conflicts. Herbs, drumming, and dance may be included in some of these practices.
Therapeutic touch	A set use of physical and nonphysical contacts that claims to relieve pain, reduce inflammation, and enhance relaxation (i.e., centering, assessing, modulating, and smoothing).
Traditional Chinese medicine	Certified and licensed (in some states) professional practitioners who are qualified to perform acupuncture, movement, and balance, and to use these in combination with various Chinese herbs that are associated with the five phases: earth, metal, water, wood, and fire and nutrition related to the Yang (male, light, fire, wood) balanced with the Yin (female, dark, water, metal, earth).
Trager work	Developed by Milton Trager, MD, a hands-on method to improve psychophysical integration (by the use of a gentle rocking motion) and mentastics (the teaching of similar techniques that may be used at home).
Transcendental meditation	Focusing on a sound, while sitting in an upright position.
Trigger point therapy	Applied pressure to nodules within the myofascia.
Western herbal medicine	Use of herbs as a “curative” source.
Yoga	Another energy therapy with the purpose of uniting the flow of physical, mental, and spiritual energy to improve health and well-being.
Zen meditation	Mostly accomplished while sitting, focuses on a thought, word, or sound, and decreases the breathing and heart rate.

Anxiety and its corresponding stressors are known to affect various body functions.⁶ Usually, blood glucose levels become elevated during periods of stress; however, they also have been known to decrease in the face of increased agitation. Relaxation therapies or energy therapies might aid in lowering glucose levels. Massage or biofeedback-enhanced relaxation training may result in less labile blood glucose levels, or overall lowered blood glucose levels in both type 1 diabetes (T1D) and type 2 diabetes (T2D). The use of biofeedback to speed up the learning process when teaching relaxation techniques also has been found to lower blood glucose levels and to aid in increased circulation.⁹Qi gong and meditation also have been used to lower glucose.¹⁰

SAFETY ISSUES AND CAUTIONS

Much of the concern regarding CAM therapies is centered on the self-administration of natural products without adequate knowledge of their efficacy and safety, especially when combined with prescription medications. Dietary supplements may not only cause side effects but also may interact with prescribed medications. Approximately one-third of American adults combine supplements and prescribed medications.¹¹ A practitioner may have to increase or decrease doses of allopathic medications when patients start or discontinue supplements. For example, St. John’s wort (SJW) commonly is used to treat depression.¹⁰ It is a known potent inducer of medications that may result in lower serum drug concentrations of a conventional medication,¹⁰ such as blood pressure (BP) medications. If a person is taking SJW, then the BP medications may have subtherapeutic concentration, which may result in lowered efficacy and the BP will rise. Consequently, the practitioner may have to increase the BP medication dose. If, however, the same patient then decides to discontinue SJW, the BP medication concentrations may be elevated, and the patient will become hypotensive. Supplements also may interact with concomitant disease states, such as hypertension. For instance, although ginseng may decrease blood glucose levels, it also may increase BP.¹⁰

Issues with purity, strength, and content of CAM therapies are important considerations. The National Institutes of Health (NIH), Office of Dietary Supplements has published a helpful online document that addresses what consumers should know about dietary supplements, including safety and risk as well as product quality issues.¹² Inadvertent constituents may be problematic. Numerous supplements have been tainted, and the U.S. Food and Drug Administration (FDA) website lists these tainted products.¹³ Impact on renal function should be considered because of problems linking supplements to renal disease. This is particularly concerning because diabetes is the leading cause of kidney disease in the U.S.¹⁴ Hepatic function also should be monitored when people with diabetes use supplements. The American College of Gastroenterology 2014 guidelines noted that 20% of drug-related liver injuries requiring hospitalization resulted from supplements.¹⁵

The patient should be educated to discuss all supplement use with the health-care team. Some patients may be reluctant to admit to their use of herbs for fear of being looked upon negatively by their health-care provider. In fact, in one study of people in the U.S. using CAM therapies, fewer than half of the thousands of survey respondents told their health clinicians that they used CAM therapy for fear of reprimand or ridicule.³ The nurse and all other clinicians should try to elicit information about use of supplements in a nonjudgmental way.

Patients must understand safety issues in the use of some herbs. Overuse or increased amounts of certain supplements can cause unfavorable reactions. Examples including diarrhea from aloe vera, constipation from berberine, renal toxicity from excess chromium intake, and bleeding reactions from fenugreek or garlic.¹⁰ Many of these herbs should not be used in pregnancy, such as fenugreek or bitter melon.¹⁰

Tables 22.4 and 22.5 list some unsafe and moderately unsafe supplements. New information regarding supplement safety may emerge and should be reviewed frequently.¹⁶ New information regarding supplement safety often emerges and frequently checking FDA website for information regarding tainted products is advised.

Table 22.4—Unsafe Dietary Supplements

Chaparral: causes liver damage

Chitosan: potentiates an anticoagulant effect

Ephedra (Mahuang): raises blood glucose, raises blood pressure, toxic

Hydrangea: leaves contain cyanide

Poke root: causes vomiting

Sassafras: is carcinogenic, causes liver damage

Yohimbine: raises blood pressure, increases anxiety

Source: Tyler.¹⁶

Table 22.5—Moderately Unsafe Dietary Supplements

Bearberry: not to be used in pregnancy or for prostate disorders

Black/blue cohosh: not to be used during pregnancy or chronic illnesses (might affect blood glucose levels)

Boneset: toxicity possible in large doses

Comfrey: causes liver damage

Juniper: causes kidney disease, not for use in pregnancy

Licorice: not for use in pregnancy, diabetes, heart disease, or hypertension

Lobelia: not to be used in pregnancy

Wormwood: not to be used in pregnancy

Source: Tyler.¹⁶

Patients should be cautioned about dietary supplement use because of the considerable variability in products and dosage forms. A typical dose recommendation is based on historical use because unlike prescription products, dose-finding studies are not researched routinely for supplements. As stated previously, an evidence-based website https://naturalmedicines.therapeuticresearch.com/ provides information on more than 1,000 supplements and also has an entire section devoted to mind and body therapies. Another useful website published by the United States Pharmacopoeia (USP; www.usp.org) is referenced in the NIH publication on what patients need to know about dietary supplements.¹² The USP website lists names of products that have been evaluated to ensure that the product contains ingredients stated on the label, that it is pure and free of contaminants (such as microbes), and that it dissolves appropriately. Additionally, some supplements may be regulated by state practice acts, so it is important to evaluate local guidelines before recommending their use.

Although more studies are emerging, most CAM therapies have not been studied adequately for diabetes treatment. The American Diabetes Association (the Association) has established guidelines regarding the use of unproven therapies.¹⁷ Therapies are classified as clearly effective, somewhat effective, unknown or unproven but possibly promising, or clearly ineffective. Operationally, the Association considers the therapy to be safe and effective if it has been approved by the FDA, supported by at least two independent well-controlled studies that have been published in a peer-reviewed scientific publication, endorsed or recommended by the Association’s Professional Practice Committee, or endorsed by a relevant or appropriate medical specialty organization.

WHO USES CAM FOR DIABETES?

Various groups and ages of individuals with diabetes may use CAM therapies. Data from the 2002 and 2007 National Health Interview Survey show that people with greater diabetes severity use complementary therapies twice as often.¹⁸ Various ethnic groups may use CAM and as many as 81.9% of individuals use herbs and vitamins to help manage diabetes.¹⁹

CAM has been used in both adults and children. In one study in which the parents of children with T1D were asked about CAM use in their children, 18.4% indicated they had used CAM, most commonly including homeopathy, vitamins and minerals, and modified diets. The parents did not question the need for insulin, but instead they had hopes of improved well-being and diabetes control.²⁰

The American Diabetes Association recognizes that many people use CAM, but does not specifically endorse its use. It is important for nurses and other practitioners to be nonjudgmental in their approach to patients using CAM. Clearly concerns arise as to scientific validity, standardization, safety, and other drug to drug interactions. Nurses can familiarize themselves with some of the more common CAM therapies and have reliable references (e.g., https://naturalmedicines.therapeuticresearch.com/) in order to be able to discuss issues surrounding the risks of injury and efficacy of these agents. The American Diabetes Associations publishes “Diabetes Risks from Prescription and Nonprescription Drugs” and “Complementary and Alternative Medicine (CAM) Supplement Use in People with Diabetes” for both patients and health-care professionals.

NATURAL PRODUCTS (SUPPLEMENTS)

Hundreds of botanicals and other supplements have been used to lower blood glucose levels; some of the commonly used products are listed in Table 22.6.¹⁰ Some of the products have been used both as foods and in supplement form to lower blood glucose levels, including aloe vera, bitter melon, fenugreek, garlic, milk thistle, and nopal (prickly pear). Unfortunately, many clinical studies that have assessed the use of CAM supplements are limited in number or fraught with design problems. Yet clinicians involved in the care of patients with diabetes often encounter patients who are using these supplements. Instead of simply telling patients not to use these products, it is important to respect the patient’s health beliefs and address their questions in an unbiased manner. It is imperative that clinicians learn about CAM supplements their patients may be taking concurrently with prescribed medications for diabetes, related comorbidities, or other disease states. It is also important for clinicians to assess accurate sources to provide information to their patients.

Table 22.6—Dietary Supplements Used for Diabetes

The ADA does not endorse any of these products. This table is provided to help clinicans learn about CAM supplements often used by patients with diabetes.

Dietary supplements to lower blood glucose
Product	Selected theorized mechanism	Comments
Aloe vera10,21	Various actions: Fiber content may delay or prevent glucose absorption and treat hyperlipidemia	– Decrease in A1C when added to oral agents; – Often used by Hispanics – Diarrhea may occur
	Various actions: – Enhances glucose-stimulated insulin secretion – Supports GLUT4 translocation – Encourages α-glucosidase inhibition – Enhances AMPK – Upregulates LDL receptors	– Greater glycemic and lipid-lowering benefit than placebo – Comparable to oral agents to decrease glucose – Effective in combination with oral agents or insulin – Constipation may occur
Bitter melon10,25,26	Various actions: – Promotes glucose uptake – Inhibits enzymes involved in glucose production – Supports AMPK activation – Encourages α-glucosidase inhibition	– Eaten as a vegetable – Variable results when studied in randomized controlled trials – Insufficient evidence – Hemolytic anemia in those with G6PD deficiency – Don’t use in pregnancy
	Various actions: – May enhance insulin effects – Modulates lipid metabolism	– Chromium picolinate is most common form used – Has been combined with biotin – Insulin-sensitizing effects
	Various actions: – Enhances insulin action – Enhances insulin signaling – Encourages α-glucosidase inhibition	– Cassia cinnamon is most studied – Decreases fasting glucose – Variable effects in lowering A1C – Possible blood thinning effect or hepatotoxicity
	Various actions: – Slows carbohydrate absorption – Inhibits glucose transport – Supports possible increase in insulin receptors	– Seeds are used for diabetes and hyperlipidemia – When added to sulfonylureas A1C may decrease – Possible blood thinning – Don’t use in pregnancy
Garlic10,36–39	Various actions: – May decrease glucose and increase insulin – Improves hepatic glycogen storage – May have an ingredient that decreases activity of factors needed for lipid synthesis	– Used for diabetes, hypertension, and hyperlipidemia – Possible blood thinning
	Various actions: – May decrease glucose transport and uptake – Modulates insulin secretion	– Two forms (Asian and American ginseng) – Many different formulations – Variable efficacy for Asian ginseng and decrease in postprandial glucose for American ginseng – May increase BP and decrease the effect of warfarin
Gymnema	Various actions: – May stimulate β-cell function and glucose uptake – Has a secretagogue-like effect	– Used in India and known as “gurmar” – Blocks “sweet taste” – Decreases A1C in both type 1 and type 2 diabetes
Milk thistle10,46–49	Various actions: – Promotes decrease in insulin resistance – Has antioxidant properties	– Decreases A1C when added to sulfonylureas – Decreases insulin requirements – Hepatoprotective
Nopal10,50	Various actions: – Slows carbohydrate absorption – Lowers lipid absorption	– Often used by Hispanics as a food – May decrease postprandial glucose
	Theoretical actions: – Releases beneficial organic and free fatty acids that counteract pathogenic microbes – Lowers insulin resistance – Has possible incretin action	– Should not be used if immunosuppressed – Separate antibiotics from probiotics administration
Selected dietary supplements to treat diabetes-related complications
Product	Selected theorized mechanism	Comments
α-Lipoic acid10,56	Theoretical actions: – Increases insulin sensitivity – May stimulate glucose transporter systems – Has antioxidant activity	– Used for neuropathy with variable results – May need to check thyroid function
	Theoretical actions: – Enhances transketolase activity and consequently inhibits pathways involved in vascular damage	– Fat-soluble form of thiamine (allows better absorption) – Used for microvascular complications with variable results

AMPK, 5' AMP-activated protein kinase; BP, blood pressure; G6PD, glucose-6-phosphate-dehydrogenase; GLUT4, glucose transporter type 4; LDL, low-density lipoprotein.

Aloe Vera, Berberine, and Bitter Melon

The high-fiber content in aloe vera may be useful for both diabetes and hyperlipidemia.¹⁰ When added to oral diabetes medications, it has resulted in a small decrease in hemoglobin A1C.²¹ Berberine is a botanical that may facilitate insulin secretion and have other glucose-lowering properties.^22,23 In a meta-analysis, berberine was found to have greater glycemic and lipid benefit than placebo; comparable glucose-lowering effects to sulfonylureas, metformin, or thiazolidinediones; and was effective in combination with other oral agents or insulin.²⁴ Bitter melon often is consumed as a vegetable and contains various ingredients that may lower glucose and promote glucose uptake.^5,25,,26 A review of randomized controlled trials (RCTs) found insufficient evidence to support its use.²⁶

Chromium, Cinnamon, and Fenugreek

Although controversial, chromium is a much-studied trace element that may help enhance insulin sensitivity.^10,27–29 Cinnamon may enhance insulin sensitivity, increase insulin receptor phosphorylation and signaling, and support other actions.^10,30,31 The Cochrane Database evaluation of 10 RCTs, however, reports that evidence is insufficient to promote cinnamon use. Fenugreek seed is a product that may affect glucose transport and carbohydrate absorption.^10,34,35A total of 69 persons on sulfonylurea with T2D were evaluated for 12 weeks–46 were given fenugreek 100.8 grams daily and 23 were given placebo. The A1C decreased from 8.02% to 6.56% in the fenugreek group (P < 0.05) and from 8.61% to 8.2% in the placebo group (P value not significant).

Garlic, Ginseng, and Gymnema Sylvestre

Garlic traditionally has been used to treat hypertension and hyperlipidemia.^10,36,37 Recent evidence suggests some blood glucose benefits when used in combination with metformin.^29,38 Garlic may work by increasing serum insulin and improving hepatic glycogen storage.^10,36,37 Different species of the same botanical may be used to treat diabetes with varied effects. For example, two different types of ginseng have been used for diabetes: Asian and American.¹⁰Ginseng may have an effect on glucose transport and uptake,^10,40 but effects have varied. A systematic review of Asian ginseng concluded that results are promising and further study is needed. The variety of different preparations used in these studies is problematic.^10,41 The leaf of Gymnema sylvestre has been used in India and found to possibly stimulate glucose uptake and stimulate β-cell function.^10,42 It has been used with insulin in T1D⁴³ and with sulfonylureas in T2D.⁴⁴ Compared with placebo in T2D, A1C decreased by 1%.⁴⁵ In a 3-month open-label study 39 persons with type 2 diabetes took gymnema 500 mg daily along with diabetes medications and 19 persons with T2D took placebo plus diabetes medications. In the gymnema group the A1C decreased 1% from 9.6 to 8.6% (P < 0.000) and in the placebo plus diabetes medications the A1C increased from 8 to 8.5% (P = 0.04).

Milk Thistle, Nopal, and Probiotics

Milk thistle (silymarin) has been used as a hepatoprotectant and may benefit diabetes by diminishing insulin resistance.^10,46,47 It may decrease insulin requirements in T2D⁴⁸ and may decrease A1C by 1.4% when added to oral agents.⁴⁹ A small randomized controlled study consisting of 3 different groups evaluated milk thistle 200 mg/day or placebo along with glibenclamide (a sulfonylurea). In the first group of milk thistle plus glibenclamide in 18 persons with T2D, the A1C decreased from 8.91 to 7.45% (P < 0.05). In the 20-person placebo plus glibenclamide group, A1C decreased from 8.76 to 8.71% (P = not significant). In the 21-person glibenclamide-only group A1C decreased from 8.78 to 8.74% (P = not significant). Nopal, or prickly pear, is a food used by many Hispanics, and is a high-fiber food that may help decrease glucose and elevated lipids.^10,50 Although there are many unknowns and several different species, probiotics have emerged as popular products and increasingly are being used to manage diabetes.^51–53 One theory is that probiotics may help manage gram-negative bacteria found in people with diabetes.⁵⁴ Probiotics have helped enhance insulin sensitivity.⁵⁵

CAM EFFECT ON COMPLICATIONS

Individuals with diabetes face numerous complications. Along with mainstream medications, various types of CAM therapies have been used to address these complications, including natural products as well as mind-body practices.

Natural Products (Supplements) for Diabetes Complications

For certain diabetes complications, many different botanical and nonbotanical supplements have been used, although none have been proven effective and patients should be cautioned in their use. Milk thistle, known for its hepatoprotective effects, may be considered if the patient has fatty liver disease, commonly seen in T2D.⁴⁷ α-Lipoic acid is a vitamin-like substance that has been well studied for neuropathy.^10,56 It has been thought to increase insulin sensitivity and has antioxidant properties.^10,56 Benfotiamine is a fat-soluble form of thiamine that provides higher blood and tissue levels and has been used for various microvascular complications.^57,58 Although evidence may be conflicting, other supplements that may be used to manage diabetes and for cardiovascular protection include coenzyme Q10 and vitamin D.¹⁰

Mind and Body Practices for Complications

Stress has a physiological as well as a mental effect on the body. Reiki has been used for relaxation purpose and also for the treatment of pain.¹⁰ Acupuncture, acupressure, magnet insoles, therapeutic touch, and yoga have been used for those suffering from neuropathy, although their efficacy is unproven. Hypnosis has been used in people with continuous discomfort to allow the mind to recognize pain-free periods as longer in time. In fact, any distracters, such as music, audio books, and transcutaneous nerve stimulator, may be helpful. Even the use of jalapeno-based topical cream containing capsaicin to produce a countereffect on the nerves of the foot or other painful areas can be effective (a good example of how a complementary treatment has become traditional medicine for people with peripheral neuropathy).

ASSESSING A PATIENT FOR CAM

Biofeedback

Before considering any of the CAM therapies, the possibility of a more serious condition always should be explored. The nurse should determine physical signs and symptoms of physiological stress, and consider whether the person is taking any supplements and what, if any, other medications (including diabetes treatment) they take. In addition:

• Take a thorough history of daily intake of food and fluids.

• Include current or past use of supplements, or other types of CAM.

• Determine whether problems exist with various body systems.

• List stressors that might be found at home, school, or work.

• Identify and explore religious and social beliefs.

• Aid the person in identifying coping mechanisms that are already in use.

• Determine what might be of use or acceptable for the individual (e.g., daily meditation to lower blood pressure, lower pulse rate, and lead to the more effective use of oxygen).⁹

Once this assessment is complete, the health-care professional can determine which CAM therapies are best suited for the patient in relation to individual input and acceptance.

Following are key factors to consider when evaluating patients with diabetes for the possible use of a CAM therapy:

• Is the kidney and hepatic function normal?

• Will the therapy affect BP?

• How will the intervention affect blood glucose levels?

Various CAM therapies have been found useful for lowering and stabilizing blood glucose levels. If a patient has developed a needle phobia, relaxation practices, hypnosis, and desensitization have been extremely helpful. Finding a qualified therapist to perform these interventions is important for that person must be cognizant of the possible side effect on blood glucose control.

An explanation of the effects of stress on the body is helpful, for example: the amygdala gets a physiologic signal when the person is experiencing fear or anger or even joy. This organ releases the chemical that signals the hypothalamus to send a message to the pituitary gland to release adrenocorticotropic hormone, which, in turn, releases cortisol from the cortex of the adrenal gland and adrenaline (epinephrine) from the medulla of the adrenal gland. Cortisol and adrenaline both result in changes in BP (usually an increase), pulse rate, and glucose levels. Adrenaline (the sympathetic nervous system responder) is responsible for releasing glucose from the liver and muscle cells and for increasing the pulse rate, and cortisol (the parasympathetic nervous system responder) aids the process in changing proteins to a glucose source in the liver and decreasing the pulse rate. Cortisol is also responsible for signaling the hippocampus to help shut down the stress response, and the amygdala helps the hypothalamus maintain a preferably less stressful state.

More stress corresponds with higher blood glucose levels. Less stress or controlled stress responses result in lowered blood glucose levels. Most important, if blood glucose levels and other chemistry parameters are not monitored along with the use of supplements and various therapies, the dangers of negative responses are definitely higher. The goal in complementary stress-reducing therapy is to teach patients to relax, and improve their physical and emotional responses to stress. Therapies may include listening to a guided imagery recording, deep abdominal relaxation breathing, quiet meditation, listening to soft music, full body massage, therapeutic touch, or any other therapy that leads to a quieter more balanced individual. Patients should be willing to check blood glucose levels and monitor their own stress levels before, and after treatments. The use of a digital thermometer to take pre- and postreadings for each intervention is also useful. It is important for patients to see and feel the improvements in their stress levels.

EDUCATIONAL AND BEHAVIORAL CONSIDERATIONS

Although many patients conduct Internet searches for information and education, the information available is not always accurate, particularly for someone with a chronic condition. Most CAM information on the Internet is written at an 11th-grade reading level,⁵⁹ and confusion can occur when the language is not thoroughly understood by the patient. When evaluating online information, it is important to consider the publishing agency or website sponsor, whether the information is being used mainly to sell products, and whether the information is accurate. The NIH Office of Dietary Supplements has a useful consumer website.⁶⁰ Reviewing online information with the patient is necessary to ensure adequate understanding.

Patient education should accompany any chosen CAM therapy and should include an explanation of what it is, its intended therapeutic effect, and the time needed to achieve the expected outcome. Educate the patient to—

• Keep adequate blood glucose reports.

• Find (or be referred to) a qualified practitioner.

• Become knowledgeable in the positive and negative results of any chosen therapy (e.g., acupuncture).

• Journal individual responses to a particular therapy.

• If a supplement is to be used, contact a knowledgeable pharmacist to determine whether the supplement conflicts with other medications needed and contact the health professional to determine whether any physical deterrent is associated with its use (e.g., liver or kidney, or cardiovascular function).

• Keep their health-care team apprised of therapies that are being used

• Assess complete lab work to determine whether general physiologic functioning is being maintained in a healthy state.

• Continue adequate blood glucose testing.

Side effects and possible adverse reactions must be discussed, and the patient should be alerted to conditions or symptoms that require immediate action, including pregnancy or changes in renal or hepatic function. In people with diabetes, the effect of the CAM therapy on both acute and chronic complications will need to be reviewed.

The physical, mental, and emotional state of the person should be weighed against the chosen therapy. Treatment should include a team effort among the health-care professional, the person with diabetes, and, if needed, a certified professional in the field of CAM therapy. Such professionals can be identified through the American Holistic Nurses Association (www.ahna.org) and the Healing Touch International (www.healingtouch.net). Education should be updated as new treatments become available or as new information regarding current CAM is discovered. The therapeutic plan may need to be adjusted when any new CAM therapy is introduced.

Continuing patient education helps patients become more familiar with their mental, physical, and even spiritual responses. Determining how patients will progress forward with some kind of intervention will help them to maintain their improvements in self-care and self-management. Maintenance therapies might include yoga, a therapeutic massage once a month, listening to relaxation tapes weekly, daily meditation, or other treatments. In all cases, continuing to follow up with the patient on a scheduled basis will prevent the person from returning to old habits.

FUTURE NURSING RESEARCH

Sociological research on the use of CAM therapies has emerged.⁶¹ This development leads to the need for relevant research to clearly determine the use, problems, and promises of this field. Resources such as useful books and Internet sites as well as monographs and literature databases are available.⁶² Rigorous research is needed from the standpoint of the effective use of these therapies and is especially salient for the field of diabetes, in which potential problems might result from the inherent disease state.⁶³ NCCAM is supportive of such research and welcomes proposals, especially those that document the specific needs found in diabetes care. Examples of ongoing NCCAM-supported research for diabetes include the effects of restorative yoga in people with metabolic syndrome, whether acupuncture improves the quality of life in people with painful diabetes-related neuropathy, whether melatonin can help control metabolic syndrome (often leading to diabetes), and whether milk thistle and N-acetylcysteine may help with diabetes-related renal damage.¹⁴

Not all of the methods or therapies have been addressed in this chapter and, certainly, not all supplements have been covered, but the information and resources included in this chapter will aid the reader in following a more responsible and safer approach to using any CAM therapy. Much is yet to be learned, but the goals are simple: 1) safely achieving normal blood glucose levels as much of the time as possible, and 2) preventing (rather than have to undo) physiologic change.

OTHER CONSIDERATIONS

Determining the effectiveness of a CAM therapy requires a trial period. For instance, if a person begins taking α-lipoic acid for polyneuropathy, a trial period of 2–3 months is needed using therapeutic dosages, such as 600–1,200 mg daily (for most other supplements, the time period is much shorter, especially if a side effect occurs). If the level of discomfort or change has not improved in that time, or if a side effect is noted, there is no value in continuing that particular therapy, and another therapy might be tried.

No single CAM modality is appropriate or effective for all people. In a 2001 survey of health-care professionals who recommend CAM therapy, the providers indicated that they prescribed the same therapy for a specific condition 34% of the time. This survey would indicate that health-care professionals are individualizing CAM prescriptions.⁶⁴

Reimbursement has become an area of concern. Even though third-party payment is increasing for such therapies as chiropractic, acupuncture, and therapeutic massage,⁶⁵ many more modalities still are not supported by insurance carriers. According to a 2002 article,⁶⁶ Medicaid reimbursement for the use of CAM therapies is increasing. This increase allows individuals who are unable to pay out of pocket to also experience appropriate CAM therapies to manage their diabetes.

Ethical considerations must be considered when using CAM. Patients have the right to be informed of the various therapeutic modalities available for the treatment of their disease. The health-care professional must be open to discussion of CAM therapies and allow the patient to pursue alternative methods, if appropriate. The health-care professional also has the responsibility to inform the patient of unintended or deleterious consequences caused by the initiation of CAM or the discontinuation of proven medical therapies.⁶⁷ As public interest increases it is possible that more patients may turn to CAM use and health-care providers must be prepared to advise patients appropriately.⁶⁸

SUMMARY

CAM has had a significant impact on 21st-century medical and nursing care.⁶⁹ Patients seek information regarding CAM and its use in their health-care regimen, and they expect that their health-care professional will be able to respond appropriately. Various surveys report different numbers, and it is unknown exactly how many Americans are using CAM therapies for diabetes. Physicians, nurses, and other health-care professionals need to foster communication with their patients about CAM therapy and provide sufficient information for adequate and safe decision-making.⁷⁰ For safe use of such therapies, health-care professionals should have a working knowledge of the prescribed CAM or be able to consult or refer to a certified professional in that field.

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ADDITIONAL READING

Dossey BM, Keegan L. Holistic Nursing: A Handbook for Practice. 6th ed. Gaithersburg, MD, Aspen, 2012

Geil P, Shane-McWhorter L. Dietary supplements in the management of diabetes: potential risks and benefits. J Am Diet Assoc 2008;108:s59–s65

Guthrie DW. Alternative and Complementary Diabetes Care. New York, Wiley, 2002

Guthrie DW. Diabetes Self-Management’s Hidden Secrets of Natural Healing. New York, Rappaport, 2007

Guthrie D, Huebscher R, Shuler P, Rauckhorst L, Miller H. Endocrine concerns. In Natural, Alternative, and Complementary Health Care Practices. Huebscher R, Shuler P, Eds. St. Louis, MO, Mosby, 2004, p. 658–713

Huebscher R, Shuler P. Natural, Alternative, and Complementary Health Care Practices. St. Louis, MO, Mosby, 2004

Micozzi MS. Fundamentals of Complementary and Alternative Medicine. 4h ed. St. Louis, MO, Saunders Elsevier, 2011

Physicians’ Desk Reference for Herbal Medicines. 5th ed. Montvale, NJ, Thompson PDR, 2012

Shane-McWhorter L. Complementary and Alternative Medicine (CAM) Supplement Use in People With Diabetes: A Clinician’s Guide. Alexandria, VA, American Diabetes Association, 2007

Snyder M, Lindquist R (Eds.). Complementary/Alternative Therapies in Nursing. 4th ed. New York, Springer, 2002

Yeh GY, Eisenberg DM, Kaptchuk TJ, Phillips RS. Systematic review of herbs and dietary supplements for glycemic control in diabetes. Diabetes Care 2003;26:1277–1294