Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath
Mr. YM was referred by his GP.
Mr. YM had a recent diagnosis of type 2 diabetes. He was referred to the diabetes educator and dietitian. When he was reviewed by the GP he stated: “It is now 3 years since I was diagnosed with diabetes. At first I was very upset and then I read lots of books about it and joined Diabetes Australia. The dietitian turned my eating habits upside down. The diabetes educator demanded too much attention and time during the day, as if I had nothing else to do or think of. I also consulted herbalists and talked to other people with diabetes. My diabetes is now so much under control without prescribed medicine that I only really think about it in the mornings. I wash my hands with soap and use a paper towel to wipe and prick my finger. Then I have a drink, take chromium and brindleberry tablets and have a good breakfast of wholemeal bread and two cooked eggs, or sardines or porridge with fruit salad, or leftover mixed vegetables. This keeps me going during the day and stops the hunger pangs. I put low calorie cream cheese on bread or nothing. I test my BGL 2 hours after every new food item and keep a diary. This helps me to know what food affects my diabetes.”
I would need to obtain clinical results such as HbA1c, blood pressure readings, lipid profile, albumin: creatinine ratio, BMI and waist circumference. I would refer Mr. YM for a foot assessment and retinal eye screening. I would also need to clarify whether he was originally prescribed oral hypoglycemic medications that he has stopped taking in preference for alternative therapies.
- What do you believe is the benefit of taking chromium and brindleberry tablets?
- What do you mean by ‘the dietitian turned my eating habits upside down’?
- Did you find the advice beneficial? If not, why?
- What is your current dietary intake?
- How have you changed your diet since you were diagnosed with type 2 diabetes?
- Are you happy with your present diet and body weight?
- Would it be more convenient for you to attend structured/self-management education during the evening or work through a CDROM/DVD at home?
I would also determine whether he had been taught the correct technique for blood glucose self-monitoring.
Depending on his responses to these questions and his degree of willingness I would:
- Refer him for structured/self-management education where he is able to develop the knowledge and skills to perform a dietary self-assessment. If he is able to analyze his own diet he will be able to make an informed decision regarding whether his diet is nutritionally balanced and benefiting his diabetes control.
- Inform him that there is very little evidence that chromium assists in the management of blood glucose control. Although some studies have shown a benefit, these were performed a long time ago in people from Asia. A recent study concluded there is no benefit in taking chromium supplements for diabetes if people are consuming a well-balanced diet (Kleefstra et al. 2006). I would inform Mr. YM that it is difficult to find any evidence for supplementing the diet with brindleberry tablets; although these supplements are unlikely to do any harm, they are likely to be expensive.
Mr. YM’s comments suggested he initially found it difficult to come to terms with the diagnosis of diabetes and found the required self-care and advice burdensome. In the 3 years since the diagnosis he appears to have come to terms with his diabetes and taken some proactive steps to manage the disease. In addition, he has declared his interest in CAM to his GP and openly discussed the CAM he uses. It would be important to determine whether he is using OHA or whether he is controlling his blood glucose using diet and CAM. It would also be useful to determine his blood glucose pattern, lipid levels, and HbA1c.
Chromium is essential to normal carbohydrate metabolism and enhances insulin sensitivity and glucose transport into cells. In addition, it may reduce total cholesterol, LDL, and triglycerides (Preuss et al. 2000) and has positive effects on bone density (McCarty 1995). Trivalent chromium (chromium picolinate) is the form most commonly used. While research into the glucose-lowering effects of chromium is contradictory, positive effects appear to be more likely in people with glucose intolerance like Mr. YM, but the effects are difficult to predict (Gunton et al. 2005). Therefore, Mr. YM’s blood glucose tests and laboratory results will be an important guide to the benefits of chromium. If he were taking OHAs as well, I would advise him about the possibility of hypoglycaemia. If he is on lipid-lowering medicines, his medicine dose requirements should be monitored.
Brindleberry (Garcinia cambogia) is often used as a weight loss herb, which induces a feeling of fullness, and may increase serotonin levels and reduce appetite. A major compound, hydroxycitric acid (HCA), which is related to citric acid in citrus fruits, blocks the conversion of sugar to starch and starch to fat. The usual dose is 750–2000 mg/day. Brindleberry is an ingredient in several weight loss formulas and is often combined with glucose-lowering herbs such as gymnema. Brindleberry can interact with conventional medicines and is contraindicated in pregnancy, but there is limited evidence about the risks and benefits (Egger et al. 1999).
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 “medicine.”
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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 #25
For more information on the book, just follow this link to Amazon.com, Managing Clinical Problems in Diabetes
Copyright © 2008 by Blackwell Publishing Ltd, UK