Our results suggest that use of and interest in complementary and alternative medicine (CAM) is high among patients with type 2 diabetes. Current and previous CAM use and knowledge of ND care were associated with greater interest in ND services for diabetes. Our findings also suggest that patients' interest in CAM may partly reflect dissatisfaction with their current diabetes care, and not solely an increased inclination to participate in self-care behaviors. In fact, respondents with greater interest in ND services reported similar levels of all self-care behaviors.
These findings differ from those of the ELDER study which found significant associations between use of CAM for diabetes and increased self-care behaviors, including more days following a healthful eating plan, monitoring glucose, engaging in foot care and adhering to medication . These divergent findings may be explained by differences in the patient populations surveyed and the analyses performed. Our study focused on patients who were not in optimal glycemic control while the ELDER study included patients with a broad range of risk factor control. As a result, the baseline HbA1c was higher in our sample than the ELDER sample (mean HbA1c: 8.1% vs. 6.8%, respectively). The narrower distribution of glycemic control in our cohort may be associated with a correspondingly narrower range of self-care behavior, thus making it more difficult to identify distinct subgroups. Because self-management for diabetes tends to be positively associated with patient education and health literacy [20–22], the ELDER study's greater variation in educational status may have led to lower mean estimates of self-care and a greater division between CAM users and non-users. Finally, our statistical comparisons were performed based on the mean number of days engaged in each behavior, whereas Bell et al. compared the proportion above specified thresholds in frequency of each behavior.
Patients in our study using more CAM practices and expressing more interest in ND care, reported higher motivation toward self-care. However, patients with greater interest in ND care rated care for their diabetes lower than patients in the less interested subgroup, despite similar ratings of their health care overall. ND interested patients also consistently scored their health care as less helpful for controlling their blood glucose, whereas all other measures of the importance of blood glucose control were equivalent for the two groups. Collectively, these findings suggest attitudes surrounding diabetes-specific health care services combined with increased motivation, rather than increased personal engagement in self-care, may mediate interest in CAM and ND care.
The findings from this survey have important clinical implications for conventional and CAM clinical care settings. In general, our sample had a high frequency of elevated cardiometabolic risk factors, and therefore risk reductions and subsequent improvements in clinical outcomes are possible if these patients were to be matched with effective services, perhaps including the one-on-one dietary and physical activity counseling recommended per preventive service guidelines . For CAM clinical care settings, our findings that CAM interest is high amongst this patient population and that CAM-interested patients are motivated to make lasting changes in their self-care, suggests an important responsibility of CAM providers to assist these patients in reaching their self-care goals. For conventional care settings, our findings suggest CAM interest by patients may be due, at least in part, to dissatisfaction with their current diabetes care. Because these patients are also motivated to change, it is important to either engage them in their current care or direct them to services where they can channel their motivation. Finally, we found 43% of patients used natural products for their diabetes care, an estimate that exceeds those published elsewhere. Given the potential for medication/natural product interactions , this high prevalence of concurrent use should encourage dialogue between patients, physicians, pharmacists, and CAM providers to ensure patient safety.
The major limitation of this survey is its restriction to members of a single health plan in Washington State. Because our sample was nearly 70% white and nearly 80% had at least some college education, our results may not apply to geographic regions with more diverse populations. In particular, because CAM use has been associated with higher levels of education in other observational studies , CAM use in our highly educated population may be greater than that in other populations.
A high priority for diabetes research is how best to design, implement and evaluate innovative programs in primary care that motivate patients to adopt self-care behaviors . Because ND practice emphasizes intensive lifestyle counseling , this model of care has the potential to improve self-care behaviors of persons with diabetes and reduce the risks of undesirable outcomes. The actual effect of ND care on clinical outcomes should be the focus of future trials. In the meantime, recognition that CAM interest may represent both increased patient motivation and dissatisfaction with current care may help all providers align patients with the necessary resources to facilitate improvements in their self-care.