Complementary alternative medicine use among patients with type 2 diabetes mellitus in the primary care setting: a cross-sectional study in Malaysia

Complementary and alternative medicine (CAM) is defined as a group of diverse medical and healthcare systems, practices, and products that are not generally considered part of conventional Western medicine [1, 2]. CAM use can be divided into five categories: biological-based therapies like herbal and dietary supplement; alternative medical systems like acupuncture or Ayurveda; energy therapies like Reiki; manipulative and body-based systems like chiropractic or massage; and mind-body interventions like tai chi or yoga [3].

CAM usage is common among patients with diabetes mellitus (DM). A better understanding of CAM use will help the medical profession be more vigilant and patient-centered, particularly during counseling sessions regarding proper use herbal remedies in the stream of modern medicine.

The prevalence of CAM usage among DM patients has a wide range (17–72.8 percent) due to different definitions in the studies [4]. Studies show that white middle-aged, being women, receiving higher education and those suffer from more than one chronic disease (especially metabolic, mental, and musculoskeletal disorders) are having a higher correlation with the use of CAM [5, 6].

Studies reported that herbal remedies, vitamins, spirituality, and exercise are common CAM therapies pursued by diabetics [4]. Among the herbal remedies, true cinnamon (Cinnamomum verum) is used commonly in the United States and Canada [7]. Bitter gourd (Momordica Charantia) and garlic (Allium Sativum) are predominantly used in India [8]. In Asia and Mediterranean, fenugreek (Trigonella Foenum Graecum) has been cultivated and used medicinally for thousands of years [9, 10]. In Malaysia, there are 12,000 plants. However, only about 1,300 herbs have been found to have therapeutic benefits [11]. This indicates that local herbs were underutilized, as not much study has been done on useful local herbs in treating or controlling diabetes [12]. Studies actually show that CAM remedies can be an important component of health self-management, depending on the patient’s financial resources, culture, and self-empowerment [13, 14]. Therefore, this study was conducted to examine the prevalence, types, reasons, and expenditures devoted to CAM among DM patients attending an outpatient primary-care clinic in Malaysia.

The prevalence of CAM usage among DM patients in this study population was high (62.5 percent). This is consistent with findings in other studies [4]. The current usage is higher than studies in the United Kingdom (17 percent) [17], Australia (23.6 percent) [18], Turkey (41.0 percent) [19], and Thailand (47 percent) [20]. This is comparable to studies in Taiwan (61 percent) [21] and Mexico (62 percent) [22] and lower compared to Korea (65 percent) [23], India (67.7 percent) [24], and the U.S. (72.8 percent) [25]. Our results were much higher compared to the local population study, where only 2.3 percent of Malaysians consumed CAM overall [26] and 0.2 percent of DM patients had experience in using CAM [27]. However, this may be underreported as other studies mention that patients with chronic diseases like diabetes tend to consume CAM compared to the general population [4, 7, 25, 28, 29]. Our result is still higher when compared to the two other local studies done at the Ipoh primary care clinic (56 percent) and Seremban Government Hospital diabetes health clinic (49.6 percent) respectively [15, 16].

Previous studies reported that the reasons for DM patients to choose such therapies may be related to the fact that diabetes is a chronic, devastating, and incurable disease. Patients may have positive views of CAM due to its organic nature (which can present fewer side-effects), concerns about doctors’ listening skills, preferences to be treated holistically, and increased availability of CAM [10, 30].

In the present study, only a small portion of patients were dissatisfied with conventional medicines (3.3 percent) and believed that traditional medicine presented more adverse effects (0.7 percent). This was surprising, since previous studies had shown dissatisfaction with conventional treatments due to ineffectiveness or unpleasant side effects were the common reasons for pursuing CAM. This is consistent with a US-based study that reported “users of alternative health care are no more dissatisfied with or distrustful of the conventional care than nonusers are” [10]. One possible reason for our findings is a change in society that links to a patient self-empowerment paradigm [31]. Most DM patients had poor blood-sugar control, as the conventional treatment requires them to be disciplined with respect to diet, lifestyle, and behavior [32, 33]. Because of this, patients tend to try CAM to optimize their health status so that they feel that they have partially contributed to the management of their disease. They believe CAM offers more personal autonomy and control over their disease [34‐36]. On the other hand, it could be related to underlying shared beliefs and cultural assumptions [37].

In our study, the main types of CAM used were herbal and dietary supplements as well as reflexology. The high consumption is not surprising, since most diabetics presumed that herbs are safer and, additionally, more affordable and easily available [16, 38, 39]. This was further supported by the fact that the total out-of-pocket expenditure was RM 52.8 ± 101.9 (US $17.0 ± USD32.8) per month. The most common sources of CAM information were recommendation from friends and families. The present study indicates that we must involve patients’ friends and the families during diabetes education counseling regarding the efficacy and potential side-effects of CAM.

Malaysia is a multiethnic, multicultural, multi-religious developing nation in which Malays form the majority, constituting 50.4 percent of the population [40]. CAM use is deeply rooted and influenced by its multicultural and religious nature. It has had ethnic diversity and this influences CAM use as well. Uses of herbs [41] like bitter gourd [42‐44], Misai Kucing (Orthosiphon Stamineus Benth) [45, 46], garlic (Allium Sativum) [47, 48], and ginseng (Panax Ginseng) [49] are believed to reduce blood sugar levels. Bitter gourd [50], also known as Momordica Charantia is a tropical vine that is widely believed to bring down blood sugar levels, despite a lack of robust evidence [43, 44, 50‐52]. Bitter gourd was widely used as ayuverda treatment in India. It was found to be the most common herb used as before 15^th century and traditional Malay medicine has been strongly influenced by the animistic culture of Hindu-Buddhism, thus the use of the bitter gourd is already deeply ingrained in the Malay population [26].

Interestingly, Sabah snake grass (Clinacanthus Nutans Lindau), an anti-inflammatory used for treating insect bites and herpes infections in Thailand [53], has also been widely used by DM patients. The users believe it contains anti-glycemic components. This may merit further study.

Belief in Islam was found to be one of the strongest predictors for pursuing CAM therapy. One explanation for this may be that CAM usage has always been embedded into the Muslim belief system and cultural heritage that is already deeply integrated into their lives [54, 55]. Indeed, Malaysia is unique in its role as a confluence of three Asian cultures, giving rise to three main traditional healing practitioners. However, Malaysia is an Islamic country, so this may explain why only a belief in the Muslim religion is a predictor of CAM usage.

Older female patients with higher levels of education and household income were more likely to be CAM users in some studies [56‐58]. However, the present study found no significant relationship in CAM usage and gender, mean age, ethnic group, education level, or total household income. This could be because the studied population was DM patients, who might be more likely to resort to CAM therapies - regardless of gender or socio-demographic status. This is supported by a U.S.-based study that reported that DM patients were 1.6 times more likely to use CAM than non-diabetics [58]. The HbA1C also was not found to have relationship as the control of diabetes was confounded by other factors such as compliance as well as other treatment modalities. This is important because, although there is increasing global interest in CAM use worldwide, doctors who practice Western medicine seem less aware about its significance and importance. By right, as health-care professionals, we should be knowledgeable about potential benefits and possible toxicities of such remedies [59]. Practitioners should provide evidence-based information on safety issues, efficacy, and potential interactions among commonly used CAM treatments – instead of brushing the topic aside or ignoring its usage.

This study showed that the prevalence of CAM consumption/use was higher among DM patients. The high consumption/use of CAM should prompt clinicians to further explore this topic, particularly among DM patients who are Muslim. In addition, future studies are recommended to conduct a randomization trial that analyzes these herbs particularly bitter gourd, Misai Kuching, garlic, and sabah snake grass – in reducing blood sugar levels in local settings.