Complementary therapy (CAM) use is increasing, as is the interest in integrative medicine. If used appropriately within a quality use of medicines (QUM) framework some CAM can help people with diabetes heal and become proactive and empowered participants in their diabetes management. CAM use is associated with both benefits and risks. An essential aspect of any management strategy is making informed decisions about the individual’s level of risk and tailoring treatment to meet their needs.

CAM has both risks and benefits for people with diabetes undergoing surgery and having investigations. Not all CAM people use is medicines and not all CAM carry the same level of risk or confer equal benefits. Adopting an holistic QUM approach can optimise the benefits and reduce the risks. A key aspect of QUM is asking about and documenting CAM use. People with diabetes who use CAM need written advice about how to manage their CAM during the surgical/investigative period. People with diabetes and renal disease and those on anticoagulants are at particular risk if they use some CAM medicines.

CAM use is increasing, possibly as part of the evolution of a new health paradigm as people try to solve modern health problems: chronic lifestyle diseases and depression. When people consider their therapeutic options they are likely to make choices that are congruent with their life philosophy, knowledge, experience, societal norms, and culture. Depending on these factors they may or may not choose to be actively involved in their care. Understanding these associations is important to understanding an individual’s self-care, adherence, and empowerment potential. For example, there is a high correlation among health beliefs, spirituality and CAM use (Hildreth & Elman 2007). In addition, there is good evidence that CAM users adopt health-promoting self-care strategies, undertake preventative health care (Kelner & Welman 1997; Garrow et al. 2006), and believe responsibility for their health ultimately rests with them.

CAM is used by >50% of the general population and the rate of use is increasing in most western countries, particularly by people with chronic diseases, especially women educated to high school level or higher, those with poor health who often have a chronic disease, are employed, and are interested in self-care (Lloyd et al. 1993; MacLennan et al. 1996; Eisenberg 1998; Egede et al. 2002; MacLennan et al. 2002). The true prevalence of CAM use by people with diabetes is largely unknown. Old studies (Leese et al. 1997; Ryan et al. 1999) found approximately 17% of people with diabetes in diabetic outpatient settings used a range of CAM, particularly herbs, massage, and vitamin and mineral supplements such as zinc. People using CAM were satisfied with their chosen therapy even if it ‘did not work’. Satisfaction with treatment improves well being (see Chapters 15 and 16). The researchers appeared to assume people used CAM to ‘control their diabetes’, however, the individuals concerned may have had different goals for using CAM from those assumed by conventional health professionals. Controlling blood glucose may not have been their primary aim. The author’s experience in a diabetes service suggests that, in many cases, people use CAM to maintain health (prevention) as well as to manage conditions such as arthritis, stress, and the unpleasant symptoms of intercurrent illness and diabetes complications, for example, nausea, pain, anxiety, and depression.

More recently, Egede et al. (2002) found people with diabetes were more likely to use CAM than non-diabetics, as were people with other chronic conditions, in a national study in the USA. In particular, people with diabetes over 65 years were the most likely group to use CAM. The most commonly used CAM was nutritional advice, spiritual healing, herbal medicine, massage, and meditation. The high usage rates in people with diabetes are hardly surprising and accord with the established demographics of CAM users.

Many health professionals, especially nurses and general practitioners (GPs), are incorporating CAM into their practice to enrich and extend their practice and provide holistic care. Many nurses and GPs who use CAM in their practices do not have formal CAM qualifications and do not effectively document or monitor the outcomes of CAM usage. In addition, they often use CAM in their own healthcare. Dunning (1998) found that 50% of a sample of 37 diabetes nurse specialists/diabetes educators used CAM in their practice and none had a CAM qualification.

The various CAM have a common underlying philosophy. Current diabetes personcentred empowerment strategies that focus on effective professional–patient partnerships, good communication, and preventative healthcare are consistent with this philosophy. CAM philosophy embodies the notion that:

• Each individual is unique, thus there is no single ‘right’ way to manage their health problems.
  
• Balance is important.
  
• The body has the capacity to heal itself. Healing is not synonymous with treating, managing or curing. The word is derived from the Anglo Saxon ‘haelen’, to make whole. Likewise, health is derived from the Anglo Saxon ‘haelth’ from ‘hal’, which also means to make whole. To achieve healing all parts and polarities need to be integrated – mind, body, and spirit within the individual’s social environment.
  
• Healing occurs by intent.
  
• A positive attitude is important to health and well being. Positivity encompasses resilience, the capacity to overcome adversity and find meaning and purpose in life (transcendence). Thus, resilience is an essential aspect of healing, particularly in chronic diseases (Lloyd 2006).
  
• The client–therapist relationship is a key aspect of the healing process.
  
• The therapist’s role is to support the innate healing potential of the individual.
  
• The mind, body, and spirit cannot be separated – what affects one affects the others (mind–body medicine). The mind–body–spirit model is embodied in eastern medical philosophy and ‘encompasses fundamental and universal elements of well being’ (Chan et al. 2006).
  
• Illness represents an opportunity for positive change (transcendence).

The following core Hippocratic tenets underpin CAM philosophy, particularly naturopathy, but they apply to all health care:

Understanding CAM philosophy is important to understanding why people use CAM. They seek answers to their health problems that match their existing beliefs and explanatory models and their health choices are part of their larger orientation on life and are not made in isolation from their beliefs and attitudes. They frequently mix and match CAM with CAM and CAM with conventional therapies to suit their needs. Adverse events can arise when due consideration is not given to the potential effects of such combinations, for example, potentially damaging medicine/herb interactions. Alternatively, CAM can enhance the effects of conventional medicines, allow lower doses of medicines to be used, reduce unwanted side effects and improve healing rates (Braun 2001).

Quality use of medicines (QUM) is a useful framework for safely integrating health options including the broad categories of CAM and conventional care (see Chapter 5). QUM is congruent with CAM philosophy. QUM is essentially a decision–making framework to achieve optimal heath care including medicines if they are indicated, that encompasses, prevention, lifestyle strategies, and risk management. QUM is an holistic, integrated framework that recognises not everybody requires medicines to maintain health.

Integrative medicine (IM) is becoming increasingly popular among health professionals, although it was originally consumer–driven. CAM and integrative medicine (IM) are not synonymous terms. IM focuses on providing best practice conventional medicine, prevention, and emotional wellbeing, thus it might encompass CAM. Likewise, QUM is not concerned with either/or choices but with providing holistic care by helping the individual make informed choices about the best way to maintain optional health. IM is defined as:

The blending of conventional medicine and complementary medicines and/or therapies with the aim of using the most appropriate of either or both modalities to care for the patient as a whole.

(Australian Integrative Medicine Association)

IM is concerned with wellness and is a flexible approach to responding to the individual and societal factors impacting on health care. The specific therapies used in IM depend on the individual, objective evidence for benefit and risk, consideration of alternative choices (QUM), cost/benefit, practitioner experience and knowledge, and/or the need to refer to other practitioners.

Significantly, ∽80% of the global population depends on herbal medicines and traditional medical systems (WHO 2002) although the medicines and systems may be different among countries and cultures. Migration and refugee displacement through war and natural disasters mean the types of CAM available outside the country of origin is increasing. Individuals import some in their new countries and these products may not be subject to good manufacturing practice or other relevant regulations that control many of the systems–related risks.

Many health institutions are concerned with regulatory and supply issues as well as benefits and risks as part of the safe use of CAM. The degree and processes for regulating CAM therapies, products and practitioners varies from country–to–country and from therapy–to–therapy. Frequently there are no formal regulatory processes in place but some CAM professional associations have stringent training and ongoing professional development requirements as part of self–regulation. Some require competence in first aid, for example, the International Federation of Aromatherapists.

The safe, effective combination of conventional and CAM care involves considering the following issues:

• The safety of the client, allowing for their personal choices.
  
• Facilitating people to make informed choices based on understanding the risks and benefits involved when using CAM, especially combining CAM and conventional care. When the patient is not competent to consent, guardianship issues may arise.
  
• The knowledge and competence of health professionals to give advice about CAM and how to refer to a suitably qualified practitioner if necessary. CAM needs to be appropriate to the individual’s physical, mental, and spiritual status and selected after considering all the options, after a thorough assessment considering potential interactions with conventional therapies. The continued suitability of CAM, like all management strategies, should be reviewed regularly because diabetes is a progressive disease and continued use may be dangerous, e.g. in people with renal and liver disease (see Chapters 8 and 10). Conventional medicine doses should be monitored and may need to be changed.
  
• Guidelines should be followed where they exist and consent is required in some settings. Policies and guidelines need to include processes for communication between CAM and conventional practitioners and for collaboration and referral mechanisms to prevent fragmented care (Dunning 2001). Where possible, guidelines should be evidence–based to support best practice. They should not be prescriptive and inflexible.
  
• Processes for monitoring outcomes and accurately documenting the effects of the therapy should be in place and objective data relevant to the aims of the therapy, should be collected.
  
• Ensuring that safe quality products are used is important. Dose variations, contamination and/or adulteration with potentially toxic substances such as heavy metals, and unsubstantiated claims made about the product can lead to serious adverse events including irreversible kidney failure (Ko 1998; Bjelakovic et al.2007).
  
• Safety data information should be available where possible and could be included with research papers or medication reference books in a portfolio on the ward.
  
• It is important that an accurate diagnosis is made and a thorough health history and assessment have been carried out prior to using any therapy. These considerations are often overlooked, especially when the person with diabetes self–diagnoses and self–treats. Such practices can result in delays in instituting appropriate management and deteriorating metabolic control.

These considerations apply equally to the selection and use of conventional therapies.

Managing diabetes effectively is about achieving balance. To achieve balance a range of therapies used holistically, is needed. For example Type 2 diabetes is a progressive, multifactorial disease, thus a single strategy is unlikely to address the underlying metabolic abnormalities or the consequent effects on mental health and well being. From a general perspective CAM can assist people with diabetes to:

• Incorporate diabetes into the framework of their lives, which encompasses two key aspects of spirituality: transformation and connectedness.
  
• Accept and manage their diabetes to achieve balance in their lives by reducing stress and depression, which can help them achieve management targets (balance) and reduce hepatic glucose output and insulin resistance. That is address spirituality, resilience and coping.
  
• Develop strategies to recognise the factors that cause stress and methods to prevent stress from occurring.
  
• Take part in decision–making, increase their self–esteem, self–efficacy and sense of being in control by improving their quality of life and enabling personal growth and transformation.
  
• Increase insulin production and reduce insulin resistance, either by the direct effects of the therapy, by reducing stress, or by enhancing the effects of conventional medications.
  
• Manage the unpleasant symptoms of diabetic complications such as pain and nausea.
  
• Preventative health care, for example, foot care to maintain skin integrity and prevent problems such as cracks that increase the potential for infection and its consequences.
  
• Teaching and learning situations to enhance learning, retention and recall.

Some specific benefits for people with diabetes have also been reported. They include: