Evidence-Based, Open-Minded: Counseling and Collaborating With Patients Who Use CAM Therapies

Consumer-driven requests have placed integrative medicine—an approach that combines treatments from conventional medicine and CAM and for which there is high-quality scientific evidence of safety and effectiveness—at the forefront of the future of medicine in the United States and around the world. To effectively collaborate with patients who are interested in CAM therapies, it is important to begin by reflecting on the patient perspective.

Patients with diabetes are 1.6 times more likely to use CAM therapies than those without diabetes.¹  Recent data from the National Health Interview Survey determined that ~ 48% of patients with diabetes use some type of CAM treatment, and 22% use some type of herbal product.²  Reasons for using CAM therapies are highly individualized and widely varied. Side effects from conventional treatments, a need to have control over one's health care, the ability to spend more time with alternative practitioners, and the increasing costs of prescription medications are commonly cited reasons for using alternative approaches.³ 

Are patients who use CAM therapies doing so because they are dissatisfied with traditional health care providers? Interestingly, research has found that CAM usage is associated with an increased likelihood of receipt of preventive care services such as the influenza vaccination.²  Rather than a rejection of conventional medicine or an unrealistic search for a cure, CAM usage often represents sense of personal responsibility for health and an attempt to live as well as possible with a chronic condition such as diabetes.⁴ 

Integrative medicine also places a special emphasis on patients' participation in their own health care. This reflects the empowerment approach to diabetes patient care: because the consequences of self-management decisions accrue first and foremost to patients, it is both their right and their responsibility to be the primary decision-makers about their condition. As diabetes health care professionals, we can assist our patients who are interested in CAM therapies by providing evidence-based information and collaborative counseling to facilitate the self-management of their diabetes.

Before diabetes health care professionals can effectively guide patients who are interested in CAM therapies, it is necessary for them to become knowledgeable about the available evidence base and areas of concern regarding biologically based CAM therapies, such as dietary supplements, herbal products, and so-called natural, but as yet scientifically unproven, therapies.

Biologically based therapies are classified as dietary supplements and, according to the Dietary Supplement Health and Education Act of 1994, are not required to undergo the same stringent approval process that is necessary for pharmaceutical products. Products classified as dietary supplements are not required to have proven safety and efficacy to be marketed.⁵  This often surprises consumers. Because of this classification, health professionals voice concern in areas such as side effects and drug interactions, product standardization, and effects on ongoing medical care, including the potential for substituting an ineffective CAM therapy for a proven therapeutic agent.

The American Diabetes Association (ADA) states that the evidence demonstrating efficacy of individual herbs and supplements in diabetes management is insufficient, noting the lack of standardization in active ingredients and the potential for interaction with other medications.⁶  The ADA has issued a position statement acknowledging the widespread use of alternative therapies and the need for cautious evaluation of these products.⁷ 

Evidence-based recommendations are the strongest foundation for evaluating the ability of CAM therapies to improve diabetes treatment outcomes. Two avenues to assist diabetes health care professionals in their evaluation of the safety and efficacy of CAM therapies include:

• The Natural Standard Database Evidence Grading System (www.naturalstandard.com), which grades the level of available scientific evidence in support of the efficacy of a given therapy for a specific indication and then provides an evidence grade ranging from A (strong scientific evidence) to F (strong negative scientific evidence).⁸ 

• The U.S. Pharmacopeia (USP; www.usp.org), which verifies the identity, strength, purity, and quality of dietary supplements and ingredients. Products that meet USP's stringent criteria display the USP Verified Dietary Supplement Mark on their product labels.⁹ 

Despite the frequent use of CAM therapies, a recent survey found that only 33.4% of patients using herbal products and dietary supplements informed their conventional health care providers.¹⁰  A survey of consumers ≥ 50 years of age noted that the most common reasons for this lack of communication were “was never asked,” “didn't know I should,” “not enough time during visits,” and “fear of being judged.”¹¹ 

Diabetes health care professionals are in a unique position to support effective self-management by encouraging an open and inviting atmosphere within the health care environment to facilitate discussion about CAM therapies. Patients often believe that because CAM therapies are “natural,” they are safer than conventional medications. Asking in a nonjudgmental way about CAM usage encourages more honest answers, enabling practitioners to fully integrate care and minimize the risks of serious medical interactions and side effects. Fragakis and Thomson¹²  provide examples of important questions to ask about CAM therapies at every patient visit. These include:

• What supplements do you use?

• What are your main reasons for taking this supplement?

• How long have you used this supplement?

• How often do you take this supplement?

• What brand of supplement do you take?

• How much of the supplement do you take? Do you ever take more than the dose shown on the label?

• What other drugs do you take, both prescription and nonprescription?

• Have you had any changes in your health or medical condition since you started taking this supplement?

• Since you've started using this supplement, have you had any reactions such as rash, stomach problems, mood changes, or nervousness?

• Are you allergic to any foods, insects, plants, or flowers? Are any of your supplements made from things that give you allergies?

• How much money do you spend on supplements? Does this cost make it hard for you to afford food or diabetes care items such as blood glucose monitoring strips or medications?

In addition, the National Center of Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health has free resources available to assist health care providers in openly discussing the use of CAM therapies. This information can be accessed by visiting the Time to Talk campaign Web site at www.nccam.nih.gov/timetotalk/.¹³ 

Certain ethnic groups such as Hispanics, Native Americans, and some Asian populations may use CAM more often because of their cultural beliefs.¹⁴  It is important for diabetes health care professionals to be respectful and responsive to learn more about patients' CAM therapy practices. The U.S. Department of Health and Human Services provides guidance on cultural competency, which can assist in promoting positive health outcomes.¹⁵ 

One of the defining principles of integrative medicine is that patients and practitioners are partners in the health care process. Counseling patients with diabetes who are interested in CAM therapies is an opportunity for diabetes health care professionals to encourage communication, provide safety and efficacy information, and discourage the use of dangerous or ineffective products. Diabetes health care professionals can take advantage of the “teachable moment” that presents itself when patients have questions about CAM therapies, using a collaborative, patient-centered approach.

Begin by helping patients identify what goal they hope to achieve when using a CAM therapy. Collaborate with patients to determine all the possible ways to achieve their goals. For example, if a patient asks about using cinnamon to control blood glucose, discuss the evidence-based risks and benefits of that option while continuing to offer additional information about lifestyle modifications such as healthful eating, physical activity, and standard medications that have proven beneficial effects in achieving blood glucose control.

Consider the characteristics of adult learners¹⁶  during CAM counseling situations. Adult learners are relevancy and goal oriented, so sessions should be focused on patients' specific areas of concern regarding CAM. Because adults integrate learning with life experiences, they need to connect the information provided with their personal knowledge base or past events. Finally, adults are practical learners, focusing on a particular problem to solve or task to complete (“I have to get my A1C down before my next visit. Can chromium help?”).

Elements of the compliance and empowerment approaches to patient education play a role in counseling and collaborating with patients who are interested in CAM therapies. Empowered patients actively ask questions about the management of their diabetes, whether focusing on CAM or more traditional medical therapies. They are active in the management of their diabetes, asking for information to use in making informed daily care decisions and taking responsibility for making these decisions.¹⁷  Collaborative counseling about the risks and benefits of CAM therapies provides an opportunity to educate patients and promote informed decision-making rather than demanding compliance with professional guidelines.

Motivational interviewing techniques can also be part of a collaborative patient counseling session on the topic of CAM therapy. Expressing empathy creates a safe and accepting environment; supporting self-efficacy reinforces patients' confidence in taking action after carefully considering the benefits and risks of a specific CAM therapy.¹⁸ 

As more individuals with diabetes use CAM therapies, diabetes health care professionals often find themselves counseling “outside the comfort zone” of their existing knowledge of these alternative therapies. An evidence-based yet open-minded approach is most effective for ensuring that patients with diabetes use safe and effective therapies while respecting their individual beliefs. Integrative medicine reaffirms the importance of the relationship between patients and practitioners. Taking the time to learn about cutting-edge therapies, evaluating their risks and benefits, then practicing counseling strategies that support self-management can make this a beneficial situation for both diabetes health care professionals and their patients.