Patti Geil, MS, RD, FADA, CDE
Geil Nutrition Communications
Lexington, KY.

Abstract

As more individuals with diabetes begin using complementary and alternative medicine (CAM) therapies, registered dietitians often find themselves acting as resources in an area that may be controversial, rapidly expanding and somewhat unfamiliar. Counseling strategies that support self-management, such as adult learning theory, the empowerment versus compliance approach, and motivational interviewing techniques, complement an open-minded, evidenced-based approach to CAM therapy in patients with diabetes.

Full Article

Introduction

“Should I be taking chromium? Will acupuncture improve my blood glucose? What about coenzyme Q10 for heart disease?” Record numbers of health-savvy consumers have become interested in the benefits being touted for complementary and alternative medicine (CAM) therapies and individuals with diabetes are 1.6 times more likely than those without diabetes to use them (1). Because of the dramatic increase in overall use of CAM in adults with diabetes, registered dietitians (RDs) often find themselves counseling patients who are interested in using these therapies. CAM therapies for diabetes tend to be controversial, and it is challenging to stay current with the rapidly expanding information as it becomes available. Many RDs may not be familiar with CAM applications, creating uneasiness when counseling a patient who wants to discuss CAM. To provide the most accurate and helpful information, nutrition professionals must carefully assess and interpret the available information about CAM therapies, then counsel patients about their potential risks and benefits while respecting the individual’s healthcare values and beliefs. Working with patients who are interested in CAM therapy may be a step outside your comfort zone, but one that can provide a challenging opportunity to put diabetes self-management counseling skills to the test.

CAM Concerns

Biologically-based CAM practices such as the use of dietary supplements, herbal products and so-called natural, but as yet scientifically unproven therapies, are of special interest and concern to RDs. Biologically-based therapies are classified as dietary supplements. According to the Dietary Supplement Health and Education Act of 1994, supplements are not required to undergo the same stringent approval process that is required for pharmaceuticals. Products classified as dietary supplements are not required to prove safety and efficacy to be marketed (2). Other areas of concern surrounding CAM use include (3):

• Side effects and drug interactions: Many serious side effects and drug interactions have been experienced by patients using unproven CAM therapies. For example, gymnema stimulates beta cell function and may cause hypoglycemia (4). Gymnema sylvestre is a plant that grows in the tropical forests of central and southern India and in parts of Africa. Herbalists in India have used the leaves of this long, slender plant as a treatment for diabetes for more than 2,000 years. Because individuals with diabetes often take a number of medications for comorbidities, the potential for drug interactions is increased.
• Product standardization: The quality of biologically based therapies depends on a number of factors including how a plant was grown and stored, which part of the plant was used, processing technique and final form of the product (capsules vs. tablets vs. water extracts). These variables may affect the pharmacologic activity of the therapy.
• Effects on ongoing medical care: CAM therapies can potentially affect medical care if an ineffective CAM therapy is substituted for a diabetes regimen or if treatment with a proven therapeutic agent is delayed while an unproven therapy is tried.

The area of biologically-based CAM therapies for diabetes is a controversial one. Although select groups of individuals with diabetes such as the elderly, pregnant or lactating women, strict vegetarians or those on calorie-restricted diets, may benefit from a multivitamin supplement, it is the position of the American Diabetes Association (ADA) that there is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes who do not have underlying deficiencies. In addition, the ADA states that the evidence demonstrating efficacy of individual herbs and supplements in diabetes management is insufficient, noting the lack of standardization in active ingredients and the potential for interaction with other medications (5). The ADA has issued a position statement acknowledging the widespread use of alternativetherapies and the need for cautious evaluation of these products (6).

Registered dietitians must also be concerned with the ethical issues that arise from the controversial nature of some CAM therapies. The sale of supplements by health professionals can also raise the question of conflict of interest. The American Dietetic Association has developed helpful resources on the legal, ethical and regulatory issues surrounding dietary supplements (7,8).

The Need for an Evidence-Based Approach

As the nutrition expert on the diabetes care team, the RD is uniquely positioned to encourage patients to communicate openly about their use of CAM, provide safety and efficacy information about supplements, and discourage use of dangerous or ineffective products. Evidence-based recommendations are the strongest foundation for evaluating the ability of supplements to improve diabetes treatment outcomes. Mathieu provides guidelines to assist RDs in evaluating current research on dietary supplements and diabetes treatment (Table 1) (9).

Another resource is the Natural Standard Database Evidence Grading System (www.naturalstandard.com), which grades the level of available scientific evidence in support of the efficacy of a given therapy for a specific indication. Levels of evidence grade include:

A: Strong scientific evidence
B: Good scientific evidence
C: Unclear or conflicting scientific evidence
D: Fair negative scientific evidence
F: Strong negative scientific evidence
Lack of Evidence: Unable to evaluate efficacy because of a lack of adequate available data For example, of the supplements most commonly used by individuals with diabetes, bitter melon, ginseng, and gymnema are graded at the B level, while aloe gel, chromium, cinnamon, fenugreek and nopal are graded at the C level (10).

Table 1. Tips for Evaluating Current Complementary and Alternative Medicine (CAM) Research

CAM Therapy: The Patient Perspective

Patients who use CAM therapies do so for various reasons, including difficulties with side effects from conventional treatments, a need to have control over one’s healthcare, the ability to spend more time with alternative practitioners, and the increasing costs of prescription medications (11). Certain ethnic groups such as Hispanics, Native Americans, and select Asian populations may use CAM more often because of cultural beliefs (12). Although it was thought that patients primarily used CAM therapy because of their dissatisfaction with traditional healthcare providers (13), recent research has found that CAM usage is associated with an increased likelihood of receipt of preventive care services (14). Rather than a rejection of conventional medicine or an unrealistic search for a cure, CAM usage often represents personal responsibility for health and an approach to living as well as possible in the context of a chronic condition such as diabetes (15).

Although a great number of patients use CAM therapies, only 33.4% of those using herbal products and dietary supplements informed their conventional healthcare providers about such use (16). One reason for this lack of open communication was the patient’s fear of being judged. A survey of consumers age 50 years or older noted that the most common reasons cited by respondents who had seen physicians but had not discussed CAM with them were that the physician never asked (42%), they did not know they should (30%) and there was not enough time during the office visit (19%) (17).

Registered dietitians have the opportunity to set an open and inviting atmosphere within the healthcare environment and ask their patients with diabetes about CAM therapy use at every medical encounter. Asking in a nonjudgmental way about CAM usage allows more honest answers, enabling practitioners to fully integrate care and minimize the risks of interactions with conventional treatments. In their book The Health Professional’s Guide to Popular Dietary Supplements (18), Fragakis and Thomson provide examples of important questions to ask about CAM therapy (Table 2).

Table 2. Key Questions for Complementary and Alternative Medicine Counseling

Counseling the CAM Patient: Strategies for Success

Using the behavioral and educational approaches that support selfmanagement of health is important when counseling a patient using or considering CAM therapies. These patients are likely to be actively involved in their own healthcare. Although their decision to use a particular therapy may appear to be unconventional, it is important to work in partnership with the patients. RDs should set the proper tone by congratulating patients for their initiative and interest in selfmanagement.

Take advantage of the “teachable moment” that presents itself when a patient has questions about CAM therapies. Begin by helping the patient identify what goal he or she hopes to achieve when using CAM therapy. Help the patient determine all the possible ways to achieve that goal. For example, if the patient wants to take chromium to lose weight, while discussing that option, offer additional information about lifestyle modifications such as healthful eating and physical activity which have proven beneficial effects. Consider the characteristics of adult learners (19) when counseling about CAM therapy:

• Adults are relevancy-oriented and goal-oriented. The educational session should focus on the specific area of concern regarding CAM, whether it is discussing acupuncture for relief of pain associated with neuropathy or the goal of improving blood glucose by using cinnamon.
• Adults integrate learning with life experiences and evaluate learning demands against experiences. They need to connect what they are learning about CAM with their personal knowledge base or past events.
• Adults are practical, focusing on learning driven by the need to solve a problem or complete a task. This characteristic may be exhibited when the patient says, “I need to take a supplement to lose 10 pounds before my daughter’s wedding.”

Elements of the compliance versus empowerment approach to patient education also play a role in this situation. Persons who actively ask questions about the management of their diabetes, whether focusing on CAM or traditional medical therapy, are empowered. They are active in the management of their diabetes, asking for information to use in making informed daily care decisions and taking responsibility for making these decisions (20). Motivational interviewing techniques are also part of a successful patient education session. Expressing empathy creates a safe and accepting environment; supporting self-efficacy reinforces the patient’s confidence in taking action after carefully considering the benefits and risks of CAM therapy (21).

Summary

While counseling patients who are interested in CAM therapy may be outside your comfort zone, it presents an excellent opportunity for RDs to learn more about cuttingedge therapies and put into practice counseling strategies that support self-management.

References

1. Edgede LE, Ye X, Zeng D, et al. The prevalence and pattern of complementary and alternative medicine use in individuals with diabetes. Diabetes Care. 2002;25:324–329.

2. Regulation on statements made for dietary supplements concerning the effect of the product on the structure or function of the body. (21 CFR Part 101). Federal Register. January 6, 2000; 65:1000–1050.

3. Shane-McWhorter L. Biological complementary therapies in diabetes. In: American Association of Diabetes Educators, The Art and Science of Diabetes Self-Management Education: A Desk Reference for Healthcare Professional. Chicago, Ill.: American Association of Diabetes Educators; 2006:432–460.

4. Jellin JM, Gregory PJ, Batz F, et al. Pharmacist’s Letter/Prescribers Letter Natural Medicines Comprehensive Database. 9th ed. Stockton, Calif., Therapeutic Research Faculty; 2007.

5. American Diabetes Association. Nutrition recommendations and interventions for diabetes [Position Statement]. Diabetes Care. 2008;31:S61–S78.

6. American Diabetes Association. Unproven therapies [Position Statement]. Diabetes Care. 2004; 27:S135–S137.

7. American Dietetic Association. Practice paper of the American Dietetic Association: dietary supplements. J Am Diet Assoc. 2005;102:460–470.

8. Thompson C, Diekman C, Fragakis AS, et al. Guidelines regarding the recommendation and sale of dietary supplements. J Am Diet Assoc. 2002;102:1158–1164.

9. Mathieu J. Sifting through the research on supplements. J Am Diet Assoc. 2007;107:912–914.

10. Natural Standard Database Evidence Grading System. Food, herbs and supplements. Available at: www.naturalstandard.com. Accessed June 12, 2008.

11. Jones RA. Complementary and alternative medicine use in diabetes. Prac Diab. 2007;26:24–26.

12. Shane McWhorter L. Complementary and Alternative Supplement Use in People With Diabetes: A Clinician’s Guide. Alexandria, VA: American Diabetes Association; 2007:7–9.

13. Astin J. Why patients use alternative medicine: results of a national study. JAMA. 1998;279:1548–1553.

14. Garrow D, Egede LE. Association between complementary and alternative medicine use, preventive care practices, and use of conventional medical services in adults with diabetes. Diabetes Care. 2006;29:15–19.

15. Thorne S, Paterson B, Russell C, et al. Complementary/alternative medicine in chronic illness as informed self-care decision making. Int J Nurs Stud. 2002;39:671–683.

16. Kennedy J. Herb and supplement use in the U.S. adult population. Clin Ther. 2005;27:1847–1858.

17. American Association of Retired Persons, National Center of Complementary and Alternative Medicine. Consumer Survey; January 18, 2007.

18. Fragakis AS, Thomson C. The Health Professional’s Guide to Popular Dietary Supplements. 3rd ed. Chicago, Ill.: American Dietetic Association; 2007:662–663.

19. Knowles MS. The Modern Practice of Adult Education: Androgogy versus Pedagogy. New York, N.Y.: New York Association Press; 1970:63–79.

20. Lorenzi GM. Implementation of diabetes education. In: Mensing C, ed. The Art and Science of Diabetes Self-Management Education: A Desk Reference for Healthcare Professionals. Chicago, Ill.: American Association of Diabetes Educators; 2006:615–632.

21. Anderson B, Funnell MM, Tang TS. Self-management of health. In: Mensing C, ed. The Art and Science of Diabetes Self-Management Education: A Desk Reference for Healthcare Professionals. Chicago, Ill.: American Association of Diabetes Educators; 2006:43–58.