Int J Diabetes & Metabolism (2009) 17:9-15

A survey amongst Complementary Alternative Medicine (CAM) users with type 2

diabetes
Hasniza Zaman Huri1, Grace Tan Poh Lian1, Samsinah Hussain1, Rokiah Pendek,2 Riyanto Teguh
Widodo1
Department of Pharmacy1, Department of Medicine2, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
____________________________________________________________________________________
Abstract
Background: This survey studied the different types of Complementary Alternative Medicine (CAM) usage, the reasons of
CAM usage and the out-of-pocket expenditure incurred by CAM users with Type 2 diabetes. Methods: This was a
descriptive, cross-sectional survey that involved 132 Type 2 diabetes patients. Results: A total of 30.2% of the patients used
dietary supplements, followed by traditional Chinese medicine (TCM) (25.1%) and traditional Malay medicine (17.9%). Two
main reasons for using CAM include: the need of patients for more control of their diabetes and also dissatisfaction with
conventional medicine. More than half of the patients spent around USD 7.2 to USD 13.9 per month on CAM as an out-of-
pocket expenditure. Less than 20% of the patients consult their physicians before using CAM. About 57% of patients stated
that their diabetes control did not show any improvement or worsen after CAM usage. Conclusion: CAM was widely used
among Type 2 diabetics as an adjunct to their conventional therapy. More than half of the patients found that CAM did not
give improvement nor worsens their diabetes control. CAM was one of the alternative treatments considered by Type 2
diabetes patients in complement with the conventional treatment for their diabetes control.

Key words: complementary alternative medicines, Type 2 diabetes, out of pocket expenditure

Introduction general, the scientific literature on the efficacy of CAM in

Diabetes mellitus is a chronic debilitating medical condition the treatment of diabetes is relatively sparse and diverse.
that affects about 33, 000 individuals in Malaysia and 300
cases of death were caused by this disease in year 2002. High rates of CAM use are well documented in the general
Diabetes mellitus is prevalent in Malaysia and has shown an population without clear clinical benefits.5 In fact, there are
increasing trend from 1996 to 2002. The number of conflicting reports in the literature about the benefits of
diabetics in Malaysia is expected to double by the year CAM and reports of adverse outcomes from the use of
2010.1 Over 90% of those with diabetes have Type 2 CAM in people with diabetes have raised several concerns.6
diabetes, including those with at young age.1 A major concern is that people with diabetes may use CAM
agents in place of clinically proven conventional diabetes
Advances in the management of diabetes mellitus in the treatment.3 Another concern is the risk of drug interaction
form of new drugs, new sources of insulin and new when these agents are used as complements to conventional
approaches to practices are recommended for physicians.2 treatment. Finally, there is concern that some of these agents
However, the growing utilization of complementary and may worsen glycemic control or even create additional
alternative medicine (CAM) represents one of the complications for people with diabetes.3
characteristic phenomenons facing scientific medicine.
Public interest in the use of CAM is on the rise. The use of Therefore this survey was conducted to improve the
CAM in the management of chronic disease is well known awareness of the usage of CAM among adult diabetes
in developed countries and is practiced to some extent in patients. The study also examined the following specific
industrialized countries. Diabetic patients are more likely to objectives:
use CAM because of the chronic course of the disease.
(1)To study the different types of CAM usage amongst
A large number of CAM treatments have been CAM users with type 2 diabetes.
recommended for diabetes. Various degree of (2)To explore the reasons of CAM usage amongst CAM
hypoglycemic effects have been attributed to most of these users with type 2 diabetes.
agents.3 However, the efficacy of most CAM therapy for (3)To calculate the out-of-pocket expenditure of CAM
glucose control and diabetes management is unproven.4 In incurred by CAM users with with type 2 diabetes.
____________________________________________
Received on: 18/06/2008 Methods
Accepted on: 29/03/2009 Study Design
Correspondence to: Hasniza Zaman Huri, Department of This was a descriptive, cross-sectional survey involving
Pharmacy, Faculty of Medicine, University Malaya
50603 Kuala Lumpur, Malaysia.
face-to-face interview with patients based on a structured
E-Mail: [email protected] questionnaire format. This study was carried out in the

9
Huri et al

Endocrine Ward and also in the Diabetic Clinic of the medicine, chiropractic, dietary supplements (Alpha-lipoic
University Malaya Medical Centre (UMMC). acid, chromium, CoQ10, garlic, magnesium, Omega-3 fatty
acids, multivitamins), traditional Malay medicine, massage
Study Population therapy, meditation, qi gong and yoga. Patients were asked
The study populations include all adult Type 2 diabetic whether they had used one or more of the above-mentioned
patients attending the Endocrine & Diabetic Wards from CAM in the three months and also the cost per month.
December 2005 to February 2006. They include both in- Patients were also asked to name other types of CAM that
patients and out-patients. For in-patients, the screening of were used but were not listed in the questionnaire.
the study population was done through the patients’ case
notes, whereas for out-patients, patients were approached An estimate of the out-of-pocket expenditure on CAM was
and identified by the interviewer. All the patients who calculated to find out the amount of money that the patient
fulfilled the inclusion criteria were selected. spend to treat his/her illness. Out-of-pocket expenditure was
defined as the fee paid by the consumers of health services
Inclusion and Exclusion Criteria directly to the provider at the time of delivery.9 In this
Inclusion Criteria: Adults of more than eighteen years of study, only those expenditure in which the patients need to
age, diagnosed with Type 2 diabetes; currently using or had pay by themselves without any source of reimbursement or
previously used CAM within the past three months. incentive for using CAM due to their Type 2 diabetes was
calculated. The questionnaire also inquired about how the
Exclusion Criteria: Patients less than eighteen years of patients learned about the CAM therapy, the reasons of
age; Diagnosed with diabetes other than Type 2 diabetes using CAM, the awareness of their physicians regarding
mellitus; Non CAM users CAM usage and whether they had consulted any physicians
Data Collection Procedure prior to use.
The study was reviewed and approved by the Medical Data Analysis
Ethics Committee, University of Malaya Medical Centre The data collected were analyzed using Statistical Package
(UMMC). A pilot study was carried out after approval from for Social Sciences (SPSS). A p value of less than 0.05 was
the Medical Ethics Committee of UMMC. considered to be statistically significant.
For the purpose of this study, the definition of CAM from
the National Centre for Complementary and Alternative For reasons of CAM usage, patients who gave their answers
Medicine7 was applied. as given below was classified to indicate dissatisfaction
with conventional medicines in diabetes:
After the eligible study population was identified, the a) Conventional medicines did not help.
patient information sheet was given to the patients. The b) Conventional medicines have too many side effects.
nature of the survey in terms of its purpose and
methodology was explained to the patients. If the patients Results
agreed to participate in the survey, consent forms were Characteristics of Studied Patients
given to obtain their signature. If the patients were Out of 150 CAM users approached during the period of the
physically incapable of responding or in any other situation interview, 132 patients agreed to be interviewed. The
that would not allow the patients to answer, family members response rate for the study was 88.0%. From the
were allowed to answer on behalf of the patients. Patients or demographic aspect, majority of the patients interviewed
family members were only interviewed after consent form were female, Chinese and in the age group of 51 to 64 years
was signed and their consents were obtained. A face-to-face old with a mean age of 55.97 ± 8.93 years old. Most of the
interview was conducted with each patient by the patients attained secondary education. The mean duration of
interviewer. diabetes mellitus was 8.91 ± 6.41 years. The Chinese
(37.1%) was the most frequent users, followed by the
Survey Instrument Malays (31.8%) and the Indians (30.3%).
The questionnaire was read by the interviewer to the
patients and patients were asked to answer. The Types of CAM Usage
questionnaire was adapted from a survey on the use of Among 132 patients that have used CAM, 85 patients
CAM.8 The original author had been notified and was duly (64.4%) were using only one type of CAM while 35.6%
acknowledged. were using two types of CAM. Dietary supplements were
the most widely used, followed by traditional Chinese
The questionnaire was divided into two sections. The first medicine and traditional Malay medicine. About 15% of the
section asked for demographic data including age, gender, patients had used other forms of CAM such as acupuncture,
ethnic group, educational level and the duration of Type 2 aromatherapy, massage, qi gong, yoga and others.
diabetes.
Traditional Malay medicine and ayurveda was used
In the second section, questions about CAM use were asked. exclusively by the Malays and the Indians. Out of 45
Based on the review of literature and the most often used patients that used TCM, 33 of them were Chinese (73.4%)
CAM, twelve types of CAM were listed namely and six were Indians and Malays, respectively (13.3%). For
acupuncture, aromatherapy, ayurveda, traditional Chinese dietary supplements, 23 Chinese (42.6%), 20 Indians

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A survey amongst Complementary Alternative Medicine (CAM) users with type 2 diabetes

(37.0%), ten Malay patients (18.5%) and a Pakistani (1.9%) patients (54.5%) believed that their condition stayed about
were using it. the same. Twenty two patients believed that their conditions
stayed about the same with the usage of TCM, 24 with
Reasons for CAM Usage dietary supplements, 12 with traditional Malay medicine,
Majority of patients (47%) used CAM because they needed eight with ayurveda and six with other types of CAM. On
more control on their diabetes. A large proportion of the the contrary, there were three patients (2.3%) that thought
patients were also dissatisfied with their conventional their diabetes condition had worsened following the CAM
medicines for diabetes regarding their side-effects (34.1%) use. All of the three patients that thought their condition had
and efficacy (16.6%). worsened with the use of traditional Chinese medicine.

This study revealed that patients learned about CAM usage Most of the patients obtained their CAM supplements or
from a variety of sources. The recommendation of CAM CAM services through the CAM practitioners (68.9%)
usage by their family or friends (68.2%) was the most followed by the pharmacists (22%). However, a small
common route followed by media (15.1%) and health care proportion of the patients obtained the CAM they used from
professionals (14.4). Only a small proportion of patients direct selling (7.6%) and other routes (1.5%).
obtained their information of CAM through books and
internet. Forty patients (30.3%) that consist of 23 male This study exposed that less than 20% of the patients
(57.5%) and 17 female (42.5%) had discontinued their declared that their physicians were aware of their CAM
CAM during the time of interview. Majority of them did not usage for the treatment of their diabetes. There was a
give any reasons of stopping the CAM (78.0%). Some of significant association between the awareness of physicians
the reasons were that: no significant effects were found after reported by the patients toward CAM usage and ethnicity
the CAM usage (17.5%) and a high total cost of diabetes (χ2=11.35, p=0.010) while gender, age, education level and
treatment (4.5%). None of the patients that used CAM had duration of diabetes showed no significant difference (Table
stopped their conventional medications. 1).

A total of 57 patients (43.2%) believed that their diabetes Prior to the use of CAM, more than 80% of the patients
condition improved after CAM use. Eighteen patients using CAM did not consult any physician, pharmacist or
believed that their conditions were better with the use of other health care professionals. Table 2 shows that only
dietary supplements, 12 with traditional Malay medicine, 10 education level of the patients demonstrated a significant
with ayurveda, four with acupuncture, two with difference between the disclosure to physicians, pharmacists
aromatherapy and one with chiropractic, massage therapy or other health care professionals on CAM usage among
and qi gong, respectively. On the other hand, another 72 patients with type 2 diabetes (χ2 =9.70, p=0.021).

Table 1: Awareness of physicians towards CAM Usage

Characteristics Aware
Yes No Total χ2 p value
Gender Male 14 44 58 1.82 0.177
Female 11 63 74
Ethnic Malay 2 39 41 11.35 0.010*
Chinese 12 38 50
Indian 10 30 40
Others 1 0 1
Age 18 to 30 1 1 2 4.43 0.351
31 to 40 0 2 2
41 to 50 9 32 41
51 to 64 12 42 54
65 and above 3 30 33
Education Level Complete Primary Education 4 39 43 5.74 0.125
Complete Secondary Education 12 48 60
College, A Levels 5 13 18
University 4 7 11
Duration of Diabetes Mellitus (years) 6.97 0.223
<1 2 6 8
1 to 3 4 20 24
4 to 5 7 11 18
6 to 10 6 29 35
11 to 15 4 18 22
>15 2 23 25
Total 25 107 132

Data was reported as number.* p value was significant (p<0.05).

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Huri et al

Table 2: Consultation with Physicians, Pharmacists or Other Health Care Professionals before CAM Usage

Characteristics Consult
Yes No Total χ2 p value
Gender Male 13 45 58 0.81 0.248
Female 12 62 74
Ethnic Malay 4 37 41 3.65 0.302
Chinese 12 38 50
Indian 9 31 40
Others 0 1 1
Age 18 to 30 1 1 2 8.50 0.075
31 to 40 0 2 2
41 to 50 12 30 42
51 to 64 10 40 50
65 and above 2 34 36
Education Level Complete Primary Education 2 40 42 9.70 0.021*
Complete Secondary Education 14 49 63
College, A Levels 6 11 17
University 3 7 10
Duration of Diabetes Mellitus 6.93 0.226
(years) <1 2 6 8
1 to 3 7 18 25
4 to 5 6 14 20
6 to 10 5 29 34
11 to 15 4 17 21
> 1 23 24
15
Total 25 107 132
Data was reported as number. * p value is significant (p<0.05).

Out-of-pocket Expenditure of CAM most of the surveys done elsewhere involved all age groups
Majority of the patients (52.3%) spent around United States compared with this study.10, 12
Dollars (USD) 7.2 to USD 13.9 per month on CAM. Five
patients (3.8%) spent less than USD 6.9 per month on CAM The duration of diabetes of Type 2 diabetes in the patients
while 43.9% of the patients spent more than USD 13.9. One studied varied from a few months to almost twenty years.
patient spent more than USD 55.5 for CAM usage. Many patients decided to indulge in CAM usage once they
were diagnosed with diabetes. Therefore patients with
More than 70% of the 132 patient were earning more than longer duration of diabetes were not necessarily having
USD 1110.3 per month. The approximate monthly greater urge to use CAM.
household incomes for around 2% of the patients were less
than USD 555.2. A significant association was noted Most of the patients that used CAM in this study had only
between the out-of-pocket expenditure and the monthly attained secondary education. This was not the case in other
household income (χ2 =138.50, p<0.001). studies where more educated patients seemed more likely to
use CAM than other individuals with diabetes.10 This
Discussion particular group of patients may be the target of appropriate
Characteristics of Studied Patients health education as more information is needed prior to
In this study, the Chinese female patients were the most CAM usage.
frequent users of CAM. The UMMC is one of the popular
choices of hospital that serve the population for the Klang Types of CAM Usage
Valley area. From some of the studies done in Western CAM has many different definitions around the globe. The
countries, there were several associations between the term CAM is mostly used in Western countries whereas
demographic factors and CAM usage.10,11 However, it was complementary or traditional medicine is commonly used in
not comparable to this study as non CAM users were not Asian countries.13 The estimate of CAM use in Malaysia
included in this study. differ considerably from those in the Western countries due
to the diversity of types of CAM used.10 The estimate of
This study showed that older patients were more likely to CAM use will vary based on the type of country, ethnicity
use CAM. The result was similar with Egede’s survey.10 and beliefs. Consistent with other recent studies, it was
The higher likelihood of CAM use in these groups of found that CAM use is common among diabetic patients.10,
14,15
patients could be due to the decreasing health status of the
patients following an increasing age. They may feel anxious
about their health condition and therefore have a tendency The type of CAM used by patients in this study differs from
to seek alternative medication for their diabetes. However, other studies. This is because the Malaysian population has

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A survey amongst Complementary Alternative Medicine (CAM) users with type 2 diabetes

unique ethnicity compared to other countries. Three main CAM usage. A study done by Barnes et al 20 also revealed
races in the Malaysian population are the Malays, the that adults aged more than eighteen years old who used
Chinese and the Indians while the survey done by Egede et CAM were more likely to do so because they assumed that
al10 involved ethnicity of Hispanic, black, white and others. the combination of CAM with conventional medicines
Egede et al10 also reported that the commonly used CAM in would help their diabetes and also they thought that it would
Western countries were nutritional advice and lifestyle be interesting to try CAM usage for the treatment of
diets, spiritual healing, herbal remedies, massage therapy diabetes.
and meditation while MacLennan et al 16 described that the
most popular forms of CAM among Australians were non- In this study, it was found that family and friends had the
prescribed vitamins, chiropractic, herbal medicines and most influencing power on the decision of the patients to
mineral supplements. The CAM used in Malaysia was more use CAM. Family members and friends have a close
traditionally-based which consists of traditional medicines relationship with the patients and they always communicate
from each of the ethnic background. with each other. Therefore, it is necessary to cooperate with
not only patients, but also with relatives and friends when
In this study, it was discovered that dietary supplements discussing the problems or treatment for diabetes. On the
were the most commonly used CAM by the patients for other hand, very few patients described the internet as a
treating diabetes. All of the dietary supplements used were source of CAM information despite its wide accessibility.
over-the-counter (OTC) products. They were widely This may be due to the lack of reliability of the information
available in all pharmacies in Malaysia and no prescriptions found through the internet.
were needed to purchase them. These suggest the popularity
of dietary supplements usage amongst Type 2 diabetes This study showed that most of the patients discontinued
patients. However, the American Diabetes Association and their use of CAM without a valid reason. This may indicate
the American Dietetic Association do not have specific that they did not, afterall, rely too much on the CAM use for
formal recommendations for the use of dietary supplements treating their diabetes. Some patients initiated CAM usage
in people with diabetes. Therefore, a wise consideration just because they want to have a try. The patients will
should be employed before dietary supplements could be choose to give up the use of CAM if no significant effect
recommended to this group of patients. was noted.
TCM was the second most commonly used CAM in this
All the patients continued their conventional medication
study. Its use was found to be highly intensive in Malaysia
while they are on CAM. This showed that CAM was used to
due to its easy accessibility. There were many TCM centers
complement conventional diabetes medications rather than
in Malaysia either in rural or urban areas. It may also be
as an alternative, because the interview was carried out in a
because the Chinese have a stronger belief in their
teaching hospital and not at public area. Most of the patients
traditionally-based TCM. Furthermore, in this study, the
visited the hospital to refill their medication or
Chinese contributed to the highest percentage in terms of
prescriptions. They only used CAM to complement the use
ethnic group.
of the diabetic medication given by the physicians. Our
The use of traditional Malay, Chinese and Indian medicine observation was comparable to other studies of CAM usage
(ayurveda) has a tendency to follow ethnic groups. among diabetic patients.10, 11 It will be important for
However, TCM had also been used by some Malay and physicians to realize that most of the individuals with
Indian patients in addition to the Chinese. On the other diabetes use CAM as a complement to conventional
hand, traditional Malay and Indian medicine were used treatment. As a result, health care providers should acquaint
almost exclusively by members of their respective ethnic themselves with the knowledge on common CAM for
groups. Strong cultural beliefs probably contribute to the diabetes, their mechanism of action, drug-drug interactions
reasons for the use of CAM pertaining to their ethnicity. A and their likely adverse effects. In addition, pharmacists
study done in Singapore17 revealed similar findings. This could play significant roles in providing the above-
may be due to the similarity of ethnic groups and population mentioned information and therefore prevent unwanted
between Malaysia and Singapore. A few patients indulged circumstances due to the use of CAM.
in meditation, qi gong and yoga after they were diagnosed
with diabetes. Although these CAM may not have any Although a large number of patients believed that their
significant effect in reducing the blood sugar levels, patients diabetes improved, they actually had used CAM along with
still use it as they believe it will reduce the stress induced by conventional medication, thus making it difficult to arrive at
their disease.18 a conclusion about the efficacy of a specific CAM
intervention. It was found in this study that all the three
Reasons of CAM Usage patients that considered their conditions worsened by CAM
Almost half of the patients interviewed in this study used usage were using TCM. It was not stated clearly what type
CAM because they believed that conventional medicine of TCM caused these incidences. The reasons why TCM
gave more adverse effects and due to the lack of trust in caused these problems were not disclosed. Conclusion on
conventional medicines. Ernst19 had stated that the safety profile of TCM could not be made as this
dissatisfaction with the conventional medicine of diabetes condition may also be caused by drug-drug interactions,
may be one of the important reasons that patients turned to drug-food interactions and other concurrent reasons.

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Huri et al

There was a large proportion of patients seeking CAM from More than half of the patients found that CAM did not give
the CAM practitioners. This result was rational as the improvement nor worsens their diabetes. CAM was one of
traditionally-based CAM can only be obtained through the alternative treatments considered by Type 2 diabetes
CAM practitioners. Most of the patients obtained their patients in complement with the conventional treatment for
dietary supplements from pharmacists. This was due to the their diabetes control.
broad set up of pharmacies in which dietary supplements are
easily accessible. References
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CAM use with their physicians. Less than a quarter of the 2. Al-Saeedi M, Elzubier AG, Bahnassi AA, Al-Dawood
CAM users informed their physicians about their CAM use. KM. Patterns of belief and use of traditional remedies
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conditions where only a small percentage of patients use with diabetes. Geriatrics Times 2004; 5: 54-59.
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shown that patients with higher income level had a greater Complementary and alternative medicine use among a
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use CAM as a complement to their conventional medicine. 13: 16-24.

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A survey amongst Complementary Alternative Medicine (CAM) users with type 2 diabetes

18. Guthrie DW, Gamble M. Energy therapies and diabetes Complementary and alternative medicine use among
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