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Managing Clinical Problems in Diabetes, Case Study #18: Complementary and Alternative Therapies

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath

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Ms. CP self-referred to a diabetes educator for advice. “I have had type 2 diabetes for 8 years and I take metformin and Diamicron (gliclazide) every day. I go to the gym four times a week and I am about 52 kg but I still have the midriff fat. I read in a magazine recently that a new product that contains white kidney beans, chromium picolinate and bitter orange can help with weight and blood glucose control. I would appreciate more information please. I am interested in natural health care. My doctor told me I have borderline diabetes. Can I continue to take glucosamine for my arthritis? Will it affect my blood glucose?”…

Complementary therapist

There are two key issues to consider: the safety of glucosamine and its efficacy. Glucosamine is a naturally occurring substance that is required for the production of various substances that make up joint tissue such as articular cartilage, tendons and synovial fluid (Braun and Cohen 2007). It has chondroprotective and anti-inflammatory activities, which appear to be the result of multiple mechanisms working together and there is strong evidence that it is effective in providing relief from some of the symptoms of osteoarthritis as well as being effective in slowing the disease progression (Towheed et al. 2005). 

Although many different forms of glucosamine are available, most clinical studies have tested glucosamine sulphate, which shows positive results. In particular, a specific patented oral formulation of glucosamine sulphate from Rottapharm, Italy, which is available as a prescription medicine in Europe, has produced the most consistent results. A 2006 Cochrane systematic review that analyzed the results of 20 clinical studies identified that non-Rotta preparations failed to produce benefits in pain and function whereas the Rotta-brand glucosamine sulphate was effective (Towheed et al. 2005). 

Besides offering patients with osteoarthritis (OA) significant symptomatic relief and long-term joint protection, glucosamine is widely considered to be safe. Currently, no serious or fatal side effects have been reported for glucosamine, in contrast to NSAIDs, which are also widely used for the symptomatic relief of OA (Anderson et al.2005). 

While some preliminary evidence suggests glucosamine may cause changes in glucose metabolism and insulin secretion similar to those seen in type 2 diabetes in both rats and humans, these findings have been disputed and to date clinical studies in humans have not demonstrated an effect on glucose metabolism (Tannis et al. 2004; Anderson et al. 2005). 

My recommendation to Ms. CP would be to continue taking glucosamine because it is safe and effective. It would seem prudent to monitor blood glucose levels if she stops using it or increase the dose to identify whether the product affects her blood glucose levels. 

Diabetes educator

It is important to stress to Ms. CP that diabetes is a serious disease and she does not have ‘borderline diabetes.’ She is obviously making an effort to actively manage her diabetes and is eating an appropriate diet and exercising, which will benefit both her diabetes and her OA.

I am not familiar with the combination product Ms. CP referred to and would ask her to bring the information to a subsequent meeting so I could find out more information for her from a CAM colleague. Bitter orange is often used in weight loss formulas to stimulate the gastrointestinal system. It may increase temperature, induce heart irregularities and increase the blood pressure. It may increase blood levels of many conventional medicines because it inhibits the P450-3A system. Bitter orange formulas should be used with care at the lowest dose and not used continuously. A proposed mechanism of action is that the amines in bitter orange stimulate beta 3 cell receptors to break down fat (in high doses) and increase the metabolic rate and possibly reduce appetite (Preuss 2002). It may have a similar effect to ephedrine on the central nervous system.

Complementary and alternative therapies

Key points:

Health professionals must be non-judgmental about people’s decision to use complementary therapies.

  • People with diabetes frequently use complementary therapies for a variety of reasons not only to reduce blood glucose.
  • Health professionals should ask about complementary therapy use.
  • Complementary therapies should be used within a quality use of medicines framework.
  • Not all complementary therapies are ‘medicines’.
References

Anderson JW, Nicolosi RJ, Borzelleca JF (2005) Glucosamine effects in humans: a review of effects on glucose metabolism, side effects, safety considerations and efficacy. Food Chemical Toxicology 43(2): 187–201.

Bakker SJL, Bilo HJG (2006) Chromium treatment has no effect in patients with poorly controlled, insulin-treated type 2 diabetes in an obese western population: a randomized, double-blind, placebocontrolled trial. Diabetes Care 29: 521–525.

Bjelakovic G, Nikolova D, Gluud LL et al. (2007) Mortality in randomized trials of antioxidant supplements for primary and secondary prevention. Systematic review and meta-analysis. Journal of the American Medical Association 297: 842–857.

Braun L (2006) Complementary medicine and safety. Chapter 3 in Dunning T (ed) Complementary Therapies in the Management of Diabetes and Vascular Disease: A Matter of Balance. Wiley and Sons, Oxford, pp 36–47.

Braun L, Cohen M (2007) Herbs and Natural Supplements – An Evidence-based Guide (2nd edn). Elsevier, Sydney.

Di Vincenzo R (2006) Nutritional therapies. Chapter 5 in Dunning T (ed) Complementary Therapies in the Management of Diabetes and Vascular Disease: A Matter of Balance. Wiley and Sons, Oxford, pp 77–146.

Egede L, Xiaobou Y, Zheng D et al. (2002) The prevalence and pattern of complementary and alternative medicine use in individuals with diabetes. Diabetes Care 25: 324–329.

Egger G, Cameron-Smith D, Stanton R (1999) The effectiveness of popular non-prescription weight loss supplements. Medical Journal of Australia 171: 604–608.

Recommended reading

Braun L, Cohen M (2006) Herbs and Natural Supplements. Elsevier, Sydney.

Dunning T (2006) Complementary Therapies in the Management of Diabetes and Vascular Disease: A Matter of Balance. Wiley and Sons, Oxford.

 

The aims of the book are to: (1) address commonly encountered diabetes management problems; (2) develop comprehensive responses from a range of relevant health professionals who suggest management approaches relevant to their area of practice. The specific health professionals who provide comments about each case depend on the specific clinical issue; and (3) stimulate thought and discussion. 

The target readership is health professionals from a range of professional backgrounds and general as well as specialist professionals such as general practitioners, nurses, dietitians, and podiatrists. The book will be particularly useful for beginner practitioners specializing in diabetes. In addition, it will provide suggestions or food for thought for more experienced practitioners. The cases will be excerpts from the book are all real and are presented exactly as the information was received from the person making the referral. General practitioners, diabetes educators and people with diabetes referred most of the cases; some were self-referrals by people with diabetes. They represent referrals to various diabetic health professionals and concern commonly encountered clinical issues.

Next Week: Case Discussion #19

For more information on the book, just follow this link to Amazon.com, Managing Clinical Problems in Diabetesalt

Copyright © 2008 by Blackwell Publishing Ltd, UK

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath