Module 203.3 en_0

Editor's Notes

1. This presentation was prepared in order to provide some basic information about complementary therapies. It does not provide details about individual CAM therapies. These are likely to vary among countries and communities within countries. The information needs to be modified to suit the country in which the presentation is used and data and experience from that country added where relevant. The lecturer should present the information objectively and in a non-judgemental manner so that participants gain a balanced view of complementary therapies and are able to join in the discussion and objectively use the information to advise people with diabetes approriately, or refer them to a knowledgeable practitioner. Note to the educator: Lecturers could use the following quote as the basis for group discussion relevant to their local are and countries. Traditional, complementary and alternative medicine attract the full spectrum of reactions — from uncritical enthusiasm to uninformed scepticism. Yet use of traditional medicine (TM) remains widespread in developing countries, while use of complementary and alternative medicine (CAM) is increasing rapidly in developed countries. In many parts of the world, policy-makers, health professionals and the public are wrestling with questions about the safety, efficacy, quality, availability, preservation and further development of this type of health care (World Health Organisation Traditional Medicine Strategy 2002- 2005)
2. A range of well-documented factors affect the health of individuals and communities. Note to the educator: In addition to the general information provided, lecturers should discuss the issues that affect heath in their local area from an anthropological and social context. This will help put complementary therapy (CAM) use into perspective. For example, CAM may be more accessible and culturally relevant than conventional medicine. Factors that influence health care in some countries and areas of countries include: A lack of conventional health care The availability of resources such as medicines, food, water and shelter Difficulty in accessing health care and resources
3. This explanation is based on the US, WHO and Cochrane Collaboration definitions. It highlights the fact that complementary therapies (CAM) are not generally accepted as part of modern diabetes care. The term generally refers to therapeutic and diagnostic disciplines outside conventional practices. Covers a wide range of therapies from well-accepted practices such as acupuncture and massage, to “fringe” therapies such as crystal therapy. Acknowledge that CAM is not a homogenous therapy. Many different therapies are grouped under the title “CAM”, just as there are many specialities included within clinical care/management. The acceptance of the various CAM therapies changes as evidence for their use accumulates. The various ways CAM is viewed in the specific area should be explored and the terminology clarified for the area. There is likely to be more than one perspective. For example, the views of health professionals may differ from those of complementary practitioners and people using complementary therapies. The different perspectives should all be considered objectively. However, participants should be aware of global trends in CAM and government initiatives in response to the increasing use of CAM.
4. Note to the educator: Course participants need to understand the philosophy underpinning complementary therapies (CAM). Each specific CAM has a particular philosophy but they have many things in common and they are outlined in this slide. Understanding the philosophy underlying CAM helps health professionals understand the ways in which the therapies are applied and the treatment goals they set out to achieve. A great deal of the philosophy is similar to that needed to manage diabetes.
5. These points are also applicable to diabetes management philosophy and to achieving optimal health outcomes.
6. There are many ways of categorising CAM, which makes it difficult to compare studies. Increasingly, the US National Institute of Health categories shown in this slide are used. However, the categories are not mutually exclusive: therapies from different categories are often combined. For example, the Chinese medicine system encompasses manipulative therapies such as massage, herbal medicines, foods and supplements, meditation, yoga, Tai chi and acupuncture. In Australia essential oils, which are derived from plants, are classified and regulated as medicines. Significantly, what some countries call CAM is called conventional in other countries.
7. The information presented in this slide and the next represents a synthesis of available literature and experience. Lecturers should include information that is specific to their region. In some countries, access to conventional care is difficult; complementary therapies are more accessible. The WHO Strategy mentioned at the beginning of the presentation is a useful resource and contains information about the frequency of CAM use in many countries. It does not specifically address diabetes. In Western countries people aged 35 - 60 are the highest users. How does that compare to your country?
8. This slide highlights the various ways people begin to use complementary therapies (CAM). The information, adapted to the local area, could be used to trigger discussion. It is important to realise that people do not necessarily abandon conventional medicine because they use CAM. Many people, including health professionals, begin to use complementary therapies after a period of significant ill-health or trauma. Many people self-diagnose or are diagnosed by the family or friends and self-treat. The diagnosis might be inaccurate and delay appropriate diagnosis and treatment. Important considerations in specific countries are the ways in which conventional and complementary therapies are integrated – or not. This issue could also be discussed. For example, there are various levels/types of integration. China is probably the only country to have a truly integrated system (WHO 2001).
9. The information in this slide is based on a range of studies but it is difficult to obtain a true estimate because most studies rely on self-report data and/or categorise or define CAM differently. However, most research suggests more than 50% of the world’s population in industrialised nations uses some form of CAM. Some countries have higher rates than others. The slide shows CAM use by people with diabetes is high and must be considered when taking a history and planning care or prescribing medicines. It also suggests there is much to gain form collaborating with CAM practitioners and traditional healers as occurs in Africa and Australia. Collaboration and interdisciplinary education could lead to greater understanding and tolerance. Appropriate communication is essential: between practitioners and people with diabetes and among practitioners.
10. Note to the educator: You could discuss these questions as a group or you could divide the participants into smaller groups to discuss and then report back to the larger group. Cultural beliefs and practices differ around the world. Some strategies people use to control blood glucose include boiling the pancreas of a cow and drinking the water, eating bitter melon or ginseng. If the participants represent different countries, it would be interesting to have them first discuss within their own country group. The World Health Organization Traditional Medicine Strategy and other references help determine usage rates and provides other useful information about these issues.
11. This slides shows that people with diabetes use CAM for a variety of reasons. Many studies show the most common reason is to maintain health and well being. Some studies show CAM use increases after diabetes is diagnosed. However, the reasons people use CAM is complex and needs to be discussed with the individual concerned in a non-judgmental way. Common therapies used include herbal medicines such as: Glucose lowering Lipid lowering Antihypertensive Vitamin and mineral supplements Antioxidants, including from dietary sources Mind-body therapies such as: Massage, often with essential oils Meditation Relaxation Yoga Counseling Acupuncture There are risks and benefits to using any therapy including conventional care.
12. The actions of many CAM glucose lowering medicines is still unclear. However, current evidence suggests many have similar actions to commonly used conventional glucose lower medicines. It should be noted that CAM medicines do not always have one active ingredient and thus are attributed with a range of actions. They often take a while for an effect to show and may produce fewer side effects. They can produce hypoglycaemia and interact with conventional medicines.
13. The information in this slide was derived from a systematic review (Yeh et al. 2003) FPG - fasting plasma glucose PPG - post prandial glucose BP - blood pressure BG - blood glucose Note: the botanical names of the plants are presented. It is essential that the botanical, not common names, of plants are used to ensure the plants are correctly identified. The common names vary among countries and in different parts of the same country. Thus, if common names are used, the possibility of incorrectly identifying a plant and consequently the possibility of an adverse event occurring, increases.
14. Many herbs are used in combination to address the various factors that contribute to hyperglycaemia. These are often combined in one CAM medicine. The reason for preparing herbal formulas is similar to the reasons conventional practitioners combine glucose lowering medicines. That is, hyperglycaemia occurs due to several underlying factors that affect glucose homeostasis. Some conventional medicines are also available as combination medicines e.g. Januvamet (Januvia and metformin).
15. In many countries food is also used as “medicine” especially in preventative care. Although there are some diets that may lead to nutritional deficiencies and may not be sustainable, CAM practitioners such as naturopaths advocate healthy, well-balanced diets similar to conventional recommendations. However, ABO blood group and ketogenic diets are not substantiated by quality evidence and can lead to nutritional imbalances. Ayurveda and Chinese medicine diets concern achieving balance. There are many CAM weight loss products and diets available on the Internet. Some of these are associated with serious adverse events e.g. diets containing Ephedra that have cause severe renal impairment.
16. The role, if any, of antioxidants in managing diabetes is unclear. Likewise, it is not clear when in the courses of the disease they should be commenced if they are useful; e.g. if they have a role in preventing complications. Commencing them at diagnosis in type 2 diabetes may be too late because many people already have complications when they are diagnosed with type 2 diabetes. Reactive oxygen species appear to play a role in inflammatory processes that lead to plaque and other tissue damage. Some studies suggest high dose supplements are needed; high doses of some vitamins and minerals also have adverse effects. There is no doubt that diabetes is associated with deficiencies in key micronutrients concerned with insulin action such as magnesium and zinc.
17. Note to the educator: Presenters are encouraged to explore their own beliefs, attitudes and fears before presenting this module. Participants can be encouraged to do the same by brainstorming conventional practitioner fears prior to seeing this list. Some of these concerns are based on inadequate knowledge about complementary therapies (CAM). Some may be well founded in some countries but not others. For example, people who use CAM may not inform their conventional practitioners. In turn, conventional practitioners usually do not ask about CAM use. Hypoglycaemic herbs can cause hypoglycaemia, especially if used with oral glucose lowering medicines. In some countries, some CAM practitioners are well trained through government accredited courses and some have to be registered to practice e.g. Chinese medicine practitioners in Victoria in Australia. Others undertake short courses or are self-taught. Likewise. products and their marketing and manufacturing processes are regulated in some countries but not others. Where they are not regulated contamination with various chemicals, conventional medicines and other substances can occur and lead to serious adverse events. There may be other factors involved in specific areas and these need to be explored and discussed as part of the lecture and as a way to invite audience participation. It is important to note that many conventional practitioners also use CAM in their personal health care and in their practices. It is also important to understand CAM training within your particular area. In many countries it needs to meet specific standards.
18. Note to the educator: The advice given for the previous slide applies to the use of this slide. The third point illustrates a process that is already under way. For example, acupuncture is recommended in several countries to manage a range of health issues. Recommendations to consider using CAM occurs largely through the accumulation of research evidence to support and validate the use of such therapies. Many complementary therapists welcome the integration on the one hand, but they lament it on the other because it is often applied in conventional practice without the underlying philosophy and associated therapies. As complementary therapies are integrated into conventional care they may cease to be part of the complementary therapists treatment options. It is also demonstrated by the fact that many conventional medicines originally derive form plants e.g. metformin was originally derived from goat’s rue (common name) Galaga officinalis.
19. The issues outlined in this slide are key safety issues. They are general to all countries. There may be specific issues in the participant’s and lecturer’s country or local area that need to be discussed and included. Safety is a complex issue and is affected by several factors. These include: Practitioner factors (conventional and complementary) including education level about complementary therapies (CAM) and competence, professional indemnity, ongoing professional development The regulation and manufacturing standards of systems such as medicines and other products; these include strategies to prevent contamination and adulteration, warning people – in countries where such policies exist – about purchasing products on the Internet and from other countries Labelling: it is essential to ensure botanical names are used for herbal medicines and essential oils rather than common names; many common names are different around the world or are applied to other herbs, which can cause confusion and lead to adverse events and toxicity
20. Many complementary therapies have a long history of safe traditional use when applied in the traditional manner. In most cases this does not mean they are used in combination with conventional therapies. Technological advances may have changed the way products are extracted and manufactured. The chemical constituents of herbal medicines may change because more advanced extraction methods enable different molecules to be extracted from the plant material. In the West people using CAM rarely reject conventional therapy use. Is that true of your country?
21. The issues raised in this slide are the same as those regarding conventional care. The lecturer should determine or discuss with participants how complementary therapies is regulated in their country. For example, in Australia, herbal medicines and essential oils are regulated under the same system as conventional medicines and are listed on the national medicines formularies and must comply with manufacturing and labelling processes. In addition, medicines are used within a framework called Quality use of Medicines that provides for using non-medicine options as first line management. Practitioners are not regulated to the same degree. This suggests that a herbal medicine may be safe, but if used by a practitioner or a person with diabetes who does not have the necessary level of knowledge or skills, its use could be unsafe. Some CAM associations have very strict self-regulation criteria that require evidence of up-to-date practice, ongoing professional development, and first aid and CPR training.
22. The evidence that is generally accepted comes from randomised controlled trials. Other evidence does exist for some therapies. For example, qualitative studies and traditional use. These are not necessarily lesser forms of evidence depending on the research question being asked. However, quality evidence is lacking for many complementary therapies (CAM). This is not to say that there is no research, but the sample sizes are often small. This means the studies are underpowered, their methods may not be appropriate to address the study question and confounding factors are not controlled or examined. The focus should be on helping participants to find quality evidence and be discerning about Internet sites and published information. Product quality control and labeling is often deficient - some products are contaminated or adulterated and there are dose variations between batches.
23. The types of adverse events likely to occur with complementary therapies are complex and depend on the specific therapy. The adverse events on this slide are reported in the literature. CAM must be approached from a broader perspective than just thinking about herbs to lower blood glucose. It is important to point out that many of these are single-case reports only. While that could represent under-reporting, one must bear in mind that the adverse events associated with conventional medicines are significant. In Australia, 140,000 hospital admissions each year are related to conventional medicines, especially in older people. In the USA, the use of unsafe medicine costs approximately 380 USD million per year in the public sector alone. These adverse events continue to occur, despite strong research evidence of their safety. Adverse events are a component of safety and the same safety issues apply to both CAM and conventional medicine. Note previous discussion about safety.
24. Some herbs cause renal or hepatic disease, resulting in significant morbidity or mortality, and have implications for conventional drug distribution, metabolism and excretion. Herbal medicines are absorbed, metabolised and distributed in the body in the same way as conventional medicines, which shows why interactions are possible when they are used with conventional medicines. The book by Braun and Cohen listed at the end of the presentation has comprehensive lists of potential interactions. It should be noted that many purported interactions are theoretical based on the actions of the herb rather than documented evidence of such interactions. Herbal medicines that lower blood glucose act in ways that are similar to the main classes of conventional glucose-lowering medicines: alpha glucosidase inhibitors, insulin sensitisers and those that increase insulin production.
25. There are benefits for people with diabetes and these need to be discussed together with the risks. In many cases, improving blood glucose control through stress reduction and improved quality of life has secondary benefits for metabolic control. In addition, there is sound evidence to support the glucose-lowering and lipid-lowering effects of some herbs and their safety. For example, glucosamine is recommended by the Australian Arthritis Foundation.
26. A number of core issues need to be considered if complementary therapies and conventional therapies are to be used together. Some of these are discussed in this slide; others have been raised in previous slides. Local service issues need to be discussed as well. The WHO Traditional Medicine Strategy is a good source of information as is a recently released Australian text: Kotsirilos V., Vietta L., Sali A. (2010) Integrative and Complementary Medicine Elsevier, Sydney.
27. Integration occurs informally.
28. Note to the educator: Each lecturer must decide the common elements in their area and the willingness of both parties to work together. The issues could be discussed with participants and this could form an additional activity. For example, Aboriginal healers in central Australia received a grant from the Australian government to write a book about how Aboriginal healers work and want to work with conventional health professionals. The book represents a positive step towards integration, reconciliation and safety.
29. This is generic advice that can be given to people with diabetes to help them use complementary therapies safely. Specific advice applies to each individual CAM therapy. It would be impossible to give advice about every CAM. However, people using the therapies need to be advised to ask CAM practitioners about how to use CAM therapies they choose, what it involves and any precautions necessary. They should also be advised to tell their CAM practitioners what conventional treatments they are using. Importantly, adjustments may be needed in both therapies during surgery, investigations, illness, therapy changes, pregnancy and puberty.