July/August 2017

Top 5 Alternative Diabetes Therapies: Are Patients Undermining Their Treatment?
By Judith C. Thalheimer, RD, LDN
Today's Geriatric Medicine
Vol. 10 No. 4 P. 14

Patients with diabetes are turning to unregulated and understudied supplements, foods, and other alternative treatments. Although some may prove useful, others carry risk of real harm.

Many individuals with diabetes are turning to home remedies and alternative treatments in an attempt to mitigate their chronic illness or prevent complications.1 Older adults are particularly at risk from unscrupulous schemes and fraudulent health claims.2 The long history of food and herbal diabetes treatments in many cultures, combined with a general rise in the use of complementary and alternative medicine (CAM) over the last few decades makes it likely that many patients are trying one or more of these remedies.3 The popularity of herbal remedies, supplements, and food "cures" certainly doesn't guarantee their safety.1 Adverse effects and interactions are possible, and patients on insulin or secretagogues (such as sulfonylureas and glinides) are at increased risk for hypoglycemia when using CAM therapies.3 A 2017 study found higher CAM use resulted in lower quality of life in people with type 2 diabetes, possibly as a result of the negative effects of using multiple therapies and their interactions with conventional care. Additionally, diabetes patients using CAM showed decreased adherence to prescribed medications.3

Complementary and alternative treatments can take the form of foods, herbal remedies, supplements, activities, or even illegally marketed diabetes drugs. Below is a detailed description of a popular choice in each of these categories.

1. Food: Apple Cider Vinegar
Various foods are purported to help with blood sugar control. Many, such as bitter melon or prickly pear cactus (nopal), are used in traditional medicine. While preliminary research on a variety of foods has found promise for some and is beginning to elucidate mechanisms of blood sugar control, most studies are either animal studies or human studies too small or flawed to be definitive. Apple cider vinegar is a popular example of a promising food whose popularity has gotten ahead of the research.

Research vs Hype
A 2004 study found that drinking 20 g of apple cider vinegar in 40 g water with one teaspoon saccharine helped improve insulin sensitivity in the hour after a high carbohydrate meal, sparking widespread interest in drinking vinegar to improve health.4 While this study included only 10 subjects with diabetes, further research appears to be backing up those findings. A 2017 meta-analysis published in Diabetes Research and Clinical Practice concluded that vinegar can be effective in reducing postprandial glucose and insulin levels and that it could be considered as an adjunctive tool for improving glycemic control; however, further research is needed.5

It is theorized that vinegar might slow the digestion of starches, delay the emptying of food from the stomach, or alter glucose production in the liver, and a small 2015 study found that, compared with a placebo, vinegar increased glucose uptake by muscles.6,7 Unfortunately the blood sugar control effect of vinegar appears to be strongest in people who do not have diabetes or prediabetes.8

Cautions
Vinegar can damage tooth enamel, and long-term use of 8 oz of vinegar per day has caused potassium deficiency. Vinegar should be mixed with water to avoid irritation. If supplementation with vinegar does in fact lower blood sugar levels, dose adjustments for diabetes medications may be necessary.9

2. Herbal Remedy: Cinnamon
Herbal remedies for diabetes abound in cultures around the world. Some herbs are used in whole form, but extracts, teas, pills, and other supplements are widely available. Cinnamon has been gaining attention in recent years for its potential health benefits, with preliminary research looking at its role in reducing inflammation, lowering cholesterol, fighting bacteria, and controlling blood sugar.10

Research vs Hype
A small study in 2003 found lower glucose, triglyceride, and LDL cholesterol levels in 30 people with type 2 diabetes who took either 1 g, 3 g, or 6 g of cinnamon supplements daily for 40 days.10 In 2013, a meta-analysis of 10 studies of cinnamon use in type 2 diabetes concluded that it was associated with a statistically significant decrease in levels of fasting blood sugar, total cholesterol, LDL cholesterol, and triglyceride levels, and an increase in HDL cholesterol levels, but had no significant effect on hemoglobin A1c levels.11

In late 2016, another group of researchers attempted a meta-analysis but concluded that the existing studies were too heterogeneous to be analyzed together. In reviewing the 11 randomized controlled trials involving nearly 700 adults with type 2 diabetes, the authors concluded that cinnamon supplements added to standard hypoglycemic medications and other lifestyle therapies had modest effects on fasting plasma glucose and hemoglobin A1c, but they stopped short of recommending its use until larger and more rigorous studies are available. Cinnamon doses in the studies reviewed ranged from 120 mg to 6,000 mg per day.12 "Cinnamon may be of some slight benefit in lowering blood sugar," says Marina Chaparro, MPH, RDN, CDE, a spokesperson for the Academy of Nutrition and Dietetics, "but there is not enough research to recommend its use." In fact, the National Center for Complementary and Integrative Health concluded in 2016 that human studies don't support using cinnamon for any health condition, and the American Diabetes Association does not recommend cinnamon's use in diabetes treatment.13,14

Cautions
Heavy use of cinnamon may cause sores on the mouth and lips and, if inhaled, this fine powder can irritate the lungs.14 High quantities of the chemical coumarin found in cinnamon can cause liver problems, particularly in those who already have liver disease, and eating large amounts could interact with blood-thinning drugs, increasing the likelihood of bleeding.13 Cassia cinnamon is higher in coumarin than Ceylon cinnamon, but Ceylon is more expensive and more difficult to find.15 Since the possibility exists that cinnamon supplementation could impact blood sugar control, patients consuming cinnamon at nondietary doses should be monitored for potential changes in hypoglycemic drug dosage.14

3. Supplement: Chromium
Studies show that people with diabetes are more likely to use supplements than people without diabetes.16 "The American Diabetes Association doesn't recommend the use of any dietary supplements for patients with diabetes," says Eileen Sturner, MBA, RD, CDE, BC-ADM, manager of the Abington-Jefferson Health Diabetes Center and Nutrition Center in Abington, Pennsylvania. "The 2017 Standards of Care state there's no clear evidence that supplements improve outcomes unless people have underlying deficiencies. There may even be some safety concerns with long-term use of antioxidant supplements like carotene and vitamins E and C." Despite the lack of official recommendations, supplements such as alpha-lipoic acid, vanadium, coenzyme Q10, and even vitamin D are all marketed as treatments for diabetes or its complications. One supplement with its roots in medical fact is chromium.

Research vs Hype
Too little chromium in the diet renders the body incapable of using glucose efficiently.17 The importance of this trace mineral was confirmed when it was discovered that patients on parenteral nutrition developed severe diabetic symptoms that were alleviated by the addition of chromium.18 But results of studies on chromium supplementation for patients with diabetes are mixed and inconclusive. A 2014 systematic review and meta-analysis concluded that chromium may have favorable effects on glycemic control, but a 2016 study in Nutrition Review concluded that the existing evidence is of low strength, chromium supplements have limited effectiveness, and there is little rationale to recommend their use for glycemic control in patients with type 2 diabetes.19,20

Cautions
The National Center for Complementary and Integrative Health states that few serious adverse effects have been linked to high intake of chromium, but instances of renal failure have been documented.3,21

4. Activity: Yoga
Alternative treatments such as acupuncture, biofeedback, guided imagery, and yoga have been studied to one degree or another as a part of diabetes self-management, with some positive preliminary results.

Research vs Hype
Yoga is one of the top 10 complementary health approaches, and its use to help treat diabetes may be growing.22 A 2016 meta-analysis in the Journal of Diabetes Investigation concluded that although further study is needed, all available evidence suggests that yoga benefits adult patients with type 2 diabetes.23 Another systematic review and meta-analysis that same year concluded that "current literature provides moderate evidence that yoga practice leads to improvement in fasting glucose compared to standard care alone," and that it may also improve lipid profile and blood pressure in people with type 2 diabetes.24

Cautions
According to the National Center for Complementary and Integrative Health, yoga is generally low impact and safe for healthy people when practiced appropriately under the guidance of a well-trained instructor. Side effects and risk of serious injury are rare although people with high blood pressure, glaucoma, or sciatica should modify or avoid some yoga poses.25 Yoga can help older adults maintain bone density, reduce anxiety, and improve balance, so it's a win for patients whether it improves blood sugar control or not.26

5. Illegally Marketed Drugs
According to the FBI, older adults are common targets of fraud schemes and are particularly susceptible to fraudulent health claims.2 Patients should be made aware that there are many unregulated, illegally marketed, and potentially dangerous diabetes drugs available.

Research vs Hype
According to the FDA, illegally marketed products promising to prevent, treat, and even cure diabetes are flooding the marketplace. These products are marketed as dietary supplements, alternative medicines, prescription drugs, over-the-counter drugs, and homeopathic products. Some fraudulent online pharmacies illegally market drugs that are not approved in the United States or sell otherwise approved prescription drug products without meeting necessary requirements.27

Cautions
These drugs may contain harmful ingredients or may be improperly marketed as over-the-counter products when they should be marketed as prescription drugs. FDA laboratory analysis found that some "all natural" products for diabetes contain undeclared active ingredients found in prescription diabetes drugs. According to the FDA, these drugs may interact in dangerous ways with prescribed medications, and there is a danger that patients taking illegally marketed drugs may decide to discontinue or delay effective treatments.27 "People with chronic or incurable diseases may feel desperate and become easy targets. Bogus products for diabetes are particularly troubling because there are effective options available to help manage this serious disease rather than exposing patients to unproven and unreasonably risky products," says Jason Humbert, a commander with the US Public Health Service, of the FDA's Office of Regulatory Affairs.

Talking to Patients
It is essential that health care professionals maintain awareness of CAM therapies and their potential risks and benefits, and communicate this information effectively with their diabetes patients. Use of CAM by patients with diabetes is prevalent, and lack of proper communication can result in disease mismanagement.3 Including questions on intake questionnaires about supplements and any other steps patients are taking to improve their health and creating a nonjudgmental atmosphere may encourage patients to be forthcoming about their efforts to improve their health or diabetes management outside of prescribed care.

Once patients have opened up about their activities, Sturner recommends open-ended questioning. "Listen, be understanding, and ask open-ended questions," Sturner says, such as, "Can you tell me why you chose to take that? Has it made a difference?"

Chaparro recommends providing patients the information they need to understand the impact of what they are doing. "Get back to basics," Chaparro says. "Let them understand how their body works, and what this treatment might do." Emphasizing the need for evidence-based practice may help. "We explain that we put patient safety first," Sturner says, "and go over what the evidence says about risks and benefits."

Many CAM treatments may be harmless, and preliminary research indicates some may be helpful, but the potential for undesirable interactions with conventional medicines, possible adverse effects, and the risk that patients will abandon effective treatments for the promise of a 'natural' cure make it imperative that health care providers be aware of common alternative treatments and enable open communication with their diabetes patients.1

— Judith C. Thalheimer, RD, LDN, is a registered dietitian and principal of JTRD Nutrition Education Services, LLC, outside Philadelphia.

TIPS FOR SAFE USE OF COMPLEMENTARY THERAPIES
Offer the following tips to patients to help them use supplements and other complementary treatments safely.

• Avoid drug interactions. Encourage patients to inform all of their health care professionals about any and all complementary treatments they are trying and to continue to take conventional medication as prescribed.

• Buy supplements and drugs from a trusted source. Supplements are unregulated. Urge patients to look for a US Pharmacopeial Convention seal on packaging to ensure that supplements come from a reputable source. More information is available at www.quality-supplements.org. To ensure an online pharmacy is legitimate, the FDA recommends the following:

• Ensure the site requires a valid prescription.
• Look for a physical address in the United States.
• Ensure licensure by a state pharmacy board.
• Check that there is a state-licensed pharmacist available to answer questions.

• Take a systematic approach. If a patient wants to try a supplement or treatment (and it can be determined that this treatment is not dangerous or detrimental to health), suggest trying it for a limited period of time. Work with patients to determine whether A1c, blood sugar control, or quality of life has improved after the trial period.

• Monitor kidney and liver function. Patients may not realize that "natural" remedies can have adverse effects. Recommend laboratory tests for kidney and liver function to ensure the supplement is not harming the patient's health.

— Sources: http://www.diabetesforecast.org/2012/feb/the-pros-and-cons-of-dietary-supplements.html; https://www.fda.gov/forconsumers/consumerupdates/ucm361487.htm

References
1. Kesavadev J, Saboo B, Sadikot S, et al. Unproven therapies for diabetes and their implications. Adv Ther. 2017;34(1):60-77.

2. Scams and safety: fraud against seniors. FBI website. https://www.fbi.gov/scams-and-safety/common-fraud-schemes/seniors

3. Kesavadev J. Efficacy and safety concerns regarding complementary and alternative medicine use among diabetes patients. J Pak Med Assoc. 2017;67(2):316-319.

4. Johnston CS, Kim CM, Buller AJ. Vinegar improves insulin sensitivity to a high-carbohydrate meal in subjects with insulin resistance or type 2 diabetes. Diabetes Care. 2004;27(1):281-282.

5. Shishehbor F, Mansoori A, Shirani F. Vinegar consumption can attenuate postprandial glucose and insulin responses; a systematic review and meta-analysis of clinical trials. Diabetes Res Clin Pract. 2017;127:1-9.

6. Weisenberger J. Vinegar: a diabetes do or don't? Diabetes Forecast. November 2014. http://www.diabetesforecast.org/2014/11-nov/vinegar-a-diabetes-do-or.html?loc=ymal

7. Mitrou P, Petsiou E, Papakonstantinou E, et al. Vinegar consumption increases insulin-stimulated glucose uptake by the forearm muscle in humans with type 2 diabetes. J Diabetes Res. 2015;2015:175204.

8. Lim J, Henry CJ, Haldar S. Vinegar as a functional ingredient to improve postprandial glycemic control-human intervention findings and molecular mechanisms. Mol Nutr Food Res. 2016;60(8):1837-1849.

9. Find a vitamin or supplement: apple cider vinegar. WebMD website. http://www.webmd.com/vitamins-supplements/ingredientmono-816-APPLE+CIDER+VINEGAR.aspx

10. Cotey S, Harris A. Can taking cinnamon supplements lower your blood sugar? Cleveland Clinic website. https://health.clevelandclinic.org/2016/10/can-taking-cinnamon-lower-your-blood-sugar/. Published October 4, 2016.

11. Allen RW, Schwartzman E, Baker WL, Coleman CI, Phung OJ. Cinnamon use in type 2 diabetes: an updated systematic review and meta-analysis. Ann Fam Med. 2013;11(5):452-459.

12. Costello RB, Dwyer JT, Saldanha L, Bailey RL, Merkel J, Wambogo E. Do cinnamon supplements have a role in glycemic control in type 2 diabetes? A narrative review. J Acad Nutr Diet. 2016;116(11):1794-1802.

13. Cinnamon. National Center for Complementary and Integrative Health website. https://nccih.nih.gov/health/cinnamon. Updated November 29, 2016.

14. Cinnamon. WebMD website. http://www.webmd.com/diet/supplement-guide-cinnamon. Updated March 8, 2017.

15. Graedon T. Which cinnamon is better for blood sugar? The People's Pharmacy website. https://www.peoplespharmacy.com/2016/08/01/which-cinnamon-is-better-for-blood-sugar/. Published August 1, 2016.

16. Herbs, supplements and alternative medicines. American Diabetes Association website. http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/other-treatments/herbs-supplements-and-alternative-medicines/#sthash.P7FlXEUn.dpuf. Updated February 20, 2014.

17. Diabetes and dietary supplements: in depth. National Center for Complementary and Integrative Health website. https://nccih.nih.gov/health/diabetes/supplements.  Updated June 23, 2016.

18. Anderson RA. Chromium and parenteral nutrition. Nutrition. 1995;11(1 Suppl):83-86.

19. Suksomboon N, Poolsup N, Yuwanakorn A. Systematic review and meta-analysis of the efficacy and safety of chromium supplementation in diabetes. J Clin Pharm Ther. 2014;39(3):292-306.

20. Costello RB, Dwyer JT, Bailey RL. Chromium supplements for glycemic control in type 2 diabetes: limited evidence of effectiveness. Nutr Rev. 2016;74(7):455-468.

21. Chromium dietary supplement fact sheet. National Institutes of Health website. https://ods.od.nih.gov/factsheets/Chromium-HealthProfessional/. Updated November 4, 2013.

22. Yoga as a complementary health approach. National Center for Complementary and Integrative Health website. https://nccih.nih.gov/news/multimedia/infographics/yoga. Updated March 15, 2016.

23. Cui J, Yan JH, Yan LM, Pan L, Le JJ, Guo YZ. Effects of yoga in adults with type 2 diabetes mellitus: a meta-analysis. J Diabetes Investig. 2017;8(2):201-209.

24. Vizcaino M, Stover E. The effect of yoga practice on glycemic control and other health parameters in type 2 diabetes mellitus patients: a systematic review and meta-analysis. Complement Ther Med. 2016;28:57-66.

25. Yoga: in depth. National Center for Complementary and Integrative Health website. https://nccih.nih.gov/health/yoga/introduction.htm. Updated September 26, 2016.

26. Paturel A. Yoga poses for your 50s, 60s and 70s — and beyond. AARP Magazine. November 2016. http://www.aarp.org/health/healthy-living/info-11-2013/health-benefits-of-yoga.html

27. Beware of illegally marketed diabetes treatments. US Food & Drug Administration website. https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm361487.htm. Updated November 10, 2016.