Use of herbal remedies by diabetic Hispanic women in The southwestern United States

250 L. JOHNSON ET AL.

Copyright © 2006 John Wiley & Sons, Ltd. Phytother. Res. 20, 250–255 (2006)

Copyright © 2006 John Wiley & Sons, Ltd.

PHYTOTHERAPY RESEARCHPhytother. Res. 20, 250–255 (2006)Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/ptr.1820

Use of Herbal Remedies by Diabetic HispanicWomen in The Southwestern United States

Lane Johnson1, Hal Strich1, Ann Taylor2, Barbara Timmermann7, Daniel Malone3,Nicky Teufel-Shone6, Rebecca Drummond6, Raymond Woosley8, Eladio Pereira4 andArt Martinez5

1Arizona Health Sciences Center, College of Medicine, Tucson, AZ, USA2Arizona Health Sciences Center, Arizona Cancer Center, Tucson, AZ, USA3Arizona Health Sciences Center, College of Pharmacy, Tucson, AZ, USA4Mariposa Community Health Center, Nogales, AZ, USA5El Rio Community Health Center, Tucson, AZ, USA6Arizona Health Sciences Center, College of Public Health, Tucson, AZ, USA7University of Kansas, College of Pharmacy, Lawrence, KS, USA8C-Path Institute, Tucson, AZ, USA

Objective: The primary purpose of this study was to examine the use and documentation of herbal remediesused by Hispanic women with Type II diabetes enrolled in two Community Health Centers in the SouthwestUSA. A secondary purpose was to review the literature on identified herbs to assess their likely effects ondiabetes.

Design: Open-ended structured interviews were conducted on a convenience sample (n ===== 23) of participants.Medical and medication charts were reviewed for the interviewed participants, and for a random sample ofenrolled Hispanic diabetic patients (n ===== 81) who were not interviewed.

Setting: Two Community Health Centers in the Southwest USA.Participants: Enrolled patient, Hispanic females with Type II diabetes.Intervention: Subjects were interviewed about their use of herbal therapies and supplements. Informationcollected from medical and pharmaceutical charts included documented use of herbal remedies; standardtherapies prescribed and diabetes control (hemoglobin A1C values). For those herbal remedies reported,literature reviews were conducted to determine if there was supporting evidence of harm or efficacy for thestated condition.

Main Outcome Measures: Reports of herbal use, and types of remedies used.Results: Among the interviewed participants, 21 of 23 (91%) reported using one or more herbal remedies.

Among a random sample of patient medical charts, seven (6.7%) contained documentation of diabetes-specificherbs, and 16 (15.4%) had documented general herb use. A total of 77 different herbal remedies wereidentified, most of which were contained as part of commercial preparations, and appeared to supplement,rather than replace standard medical therapy for diabetes.

Conclusion: Use of herbal therapies is not uncommon among diabetic patients. Many of the herbs reportedhave potential efficacy in treating diabetes or may result in adverse effects or interactions. In practical use,however, the herbs reported in this study are unlikely to have a significant effect on clinical outcomes indiabetes, either positively or negatively. Copyright © 2006 John Wiley & Sons, Ltd.

Keywords: Hispanic females; herbal remedies; diabetes; interviews; medical charts.

Received 7 March 2003Accepted 23 September 2005

* Correspondence to: Dr H. Strich, Arizona Health Sciences Center,College of Medicine, Tucson, AZ, USA.Contract/grant sponsor: US Agency for Healthcare Research and Qualityto the Arizona Center for Education and Research on Therapeutics(www.ArizonaCERT.org)

INTRODUCTION

Treatment and control for diabetes typically includesdiet, exercise, home blood glucose testing, and in manycases, oral hypoglycemia and/or insulin. Herbal rem-edies are also used by groups such as Mexican Ameri-cans in the southwestern USA, where traditional plantmedicines have historically been used to treat a varietyof ailments (Eisenberg et al., 1993; Trotter, 1981).Understanding the use of herbal remedies, their hypo-glycemic properties, and potential adverse effects and

drug interactions, is important in designing effectivetreatment programs, yet few studies have examined thisin detail.

Diabetes is a major and increasing public health pro-blem, and trends show that minority populations aredisproportionately affected by diabetes. The purposesof this study were to: (1) identify different types ofherbal remedies used by Hispanic women with Type IIdiabetes; (2) examine health characteristics associatedwith the use of herbal remedies; (3) determine thedegree to which herbal remedies are documented inpatient charts and on drug lists; and (4) evaluate thepotential efficacy associated with use of these remediesbased on a review of the scientific literature. This infor-mation will enable practitioners to anticipate andrecognize the use of herbal remedies among personswith diabetes, and to develop methods to address bothdesired and undesired effects.

HERBAL REMEDIES IN DIABETES 251


BACKGROUND AND METHODS

Study participants were recruited through two Com-munity Health Centers (CHCs) located in southernArizona. Community Health Centers typically providehealth care services to low-income, minority, medicallyhigh-risk, underserved populations.

Study participants had to meet the following criteriato be eligible for the study: (1) female; (2) Hispanicethnicity based on CHC enrollment records; (3) aged18 years or older; (4) diagnosed with Type II diabetesat least one year prior to entry to the study; (5) en-rolled in one of the participating southern ArizonaCHCs. Hispanics living in the southwest USA wereselected because of their extremely high rates of TypeII diabetes, and because they generally experience pooraccess to health care for a number of reasons, primarilyeconomic. Women were selected for the central role itis believed they perform as caretakers in the family.

Information was obtained from subject interviewsabout the use of standard medications and over-the-counter (OTC) medications, herbal therapies and sup-plements. Identification of species was obtained fromlabels of sample substances shown to the researchers,and converted to standard nomenclature. Resourceswere not available to chemically analyse the specimensand validate their constituent elements. Additional in-formation collected included: age, length of time livingin USA, year first diagnosed with diabetes, diabetessymptoms, health problems or conditions, frequency ofphysician visits, how the subject heard about herbalremedies, dietary practices, physical activity and par-ticipation in other diabetes education activities.

Medical and medication records were also reviewedfor interviewed participants, and for an additional ran-dom sample of 81 enrolled Hispanic diabetic femalepatients, a total of 104 patient charts. Patient medicaland medication charts were reviewed to examine stand-ard patient treatment with respect to documentation ofherb use, and to evaluate differences in diabetes con-trol as measured by hemoglobin A1C values betweenstudy participants reporting using herbs and the random

sample of patient medical charts. Pharmacists were alsoasked if they discuss herb use with patients.

RESULTS

Participants interviewed at the two CHC sites were com-parable with respect to age, time since diagnosis andhemoglobin A1C values. Patient characteristics fromthe random review of medical charts were also similarwith respect to the same measures. Lastly, no significantdifferences were found between study subjects and ran-dom patient medical charts with respect to age, lengthof time since first diagnosed with diabetes, and diabe-tes control as measured by hemoglobin A1C values.

Participants reported experiencing a number ofdiabetes-related health conditions, including (in rankorder) problems with eyes, heart, feet and kidney, anddiabetes-related symptoms, including itching, burningand numbness in hands and feet, problems with urina-tion, fatigue, bad moods, weight loss and thirst. Nocorrelation was found between either reported healthconditions or diabetes symptoms, and the number ofherbs used.

Almost 40% of subjects reported hearing about herbaland OTC remedies from friends, and 35% from familymembers. Only one participant had heard about theseremedies from an herbalist (curandero). Another 22%reported ‘other’ sources of information about theseremedies, including radio, advertisements, magazinesand television. None reported their physician or phar-macist was a source of information on herbal remedies.

More than 90% (n = 21) of participants reportedusing one or more herbal remedies. A total of 77 dif-ferent herbal remedies were identified (see Table 1,which includes the scientific, common and Spanishnames). Many (64, or 83%) herbal remedies are con-tained as part of commercial preparations (see Table2). The use of herbal remedies by informants wascomplex and varied extensively. Informants reportedusing several formulations including (in rank order):(1) tablets or capsules containing commercially prepared

Table 1. Herbal remedies reported

Species name Family Common Name Spanish Name

Agastache mexicana Lamiaceae Mexican Giant Hysopp ToronjilAllium sativum Lilliaceae Garlic AjoAlnus acuminata Betulaceae Mexican Alder Quina rojaAloe socotrina Aloeaceae Aloe Vera SavilaAloe vera Aloeaceae Aloe Vera SavilaAmaranthus sp. Amaranthaceae Amaranth Amaranto, QuelitesAmbrosia spp. Asteraceae Ragweed CicurraAnanas comosus Bromeliaceae Pineapple PiñaApium graveolens Apiaceae Celery ApioArctostaphylos spp. Ericaceae Camomile ManzanillaAscophyllum nodosum scorpiodes Fucaceae Kelp plant None identifiedAzadirachta indica Meliaceae Neem (100% neem powder) NeemBerberis spp. Berberidaceae Barberry AgritoBrickellia cavanillesii Asteraceae Brickelbush HamulaBrickellia spp. Asteraceae Brickelbush ProdigiosaBriza media Poaceae St. Peter’s Tears, Quaking Grass Lagrimas de San PedroCaesalpinia pulcherrima Fabaceae Bird of Paradise TabachinCamellia sinensis Theaceae Black tea, Green tea, Oolong tea Tetohuxtle, Te Verde, Te Negro



Table 1. (Continued)

Species name Family Common Name Spanish Name

Capsicum annum Solanaceae Capsicum fruit, Pepper ChiliCassia angustifolia Fabaceae Senna Hoja SenCasuarina equisetifolia Casuarinaceae She Oak, Australian Pine PinoCecropia obtusifolia Cecropiaceae None identified ChancarroCecropia spp. Cecropiaceae Trumpet tree Chancarro rojoChiranthodendron pentadactylon Sterculiaceae Manita flower Manita, Flor ManitaChlorella regularis Oocystaceae Chlorella None identifiedChondrus crispus Gigartinaceae Irish plant moss None identifiedCitrus sinensis Rutaceae Orange juice Jugo de naranja, Canotio, AzarCitrus spp. Rutaceae Lime juice LimónCitrus spp. Rutaceae Grapefruit ToronjaCordia boissieri Boraginaceae Cordia AnacahuiteCrataegus mexicana Rosaceae Hawthorn berries TejocoteCrataegus oxycanthoides Rosaceae Hawthorn berries None identifiedCrataegus spp. Rosaceae Hawthorn Raiz tejocoteCroton cascarrilma Euphorbiaceae None identified CopalkinCurcumis sativus Cucurbitaceae Cucumber PepinoCyamopsis tetragonoloba Fabaceae Guar gum None identifiedElettaria cardamomum Zingiberaceae Cardamon MalabarEquisteum spp. Equisetaceae Horsetail Cola de caballoEucalyptus globulus Myrtaceae Eucalyptus EucaliptoEysenhardtia polystachya Fabaceae Kidneywood Palo azulGeum urbanum Rosaceae None identified ChancarroGinkgo biloba Ginkgoaceae Maidenhair tree None identifiedGnaphallium conoldeum Asteraceae Cudweed GordoloboHaematoxylum brasiletto Fabaceae Brasil wood Palo de brasilHordeum spp. Poaceae Barley None identifiedHeterotheca inuloides Asteraceae Telegraph plant ArnicaHibiscus sabdariffa Malvaceae Hibiscus JamaicaHymenaea courbaril Fabaceae Jatoba AlgarroboIbervillea sonorae Curcurbitaceae Curcurbitaceae WerequeJuglans nigra Juglandaceae Black Walnut hulls Hoja de nogalJuliana adstringens Julianaceae None identified CuachalatlateJuniperus flaccida Cupressaceae None identified EnebroJusticia spicigera Acanthaceae Mexican Honeysuckle, Firecracker bush MuicleKrameria greyi Krameriaceae Ratany CosaguiLinum usitatissimum Linaceae Flaxseed LinasaLippia alba, L. geminata Verbenaceae Bushy Lippia Hierba buenaMalus sylvestris Rosaceae Apple ManzanaMarrubium vulgare Lamiaceae Horehound MarrubioMedicago sativa Fabaceae Alfalfa LinasaMentha spicata Lamiaceae Spearmint Hierba buenaMorinda citrifolia Rubiaceae Indian Mulberry NoniOpuntia ficus indica Cactaceae Prickly Pear Cactus NopalOpuntia lindheimeri Cactaceae Prickly Pear Cactus NopalOpuntia spp. Cactaceae Prickly Pear Cactus NopalOpuntia ficus-indica Cactaceae Prickly Pear Cactus NopalOpuntia streptocantha Cactaceae Prickly Pear Cactus NopalPachycereus marginatus Cactaceae None identified Cinita (de los 5 piquitos)Passiflora alata Passifloraceae Passion flower Pasiflor, PasionariaPetroselinum sativum Apiaceae Parsley PerejilSpirulina platensis Oscillatociaceae Spirulina None identifiedRorippa nasturtium aquaticum Brassicaceae Watercress None identifiedSmilax aristolochiifolia Smilacaceae Sarsaparilla root ZarzaparrillaSmilax officinalis Smilacaceae Sarsaparilla root ZarzaparrillaSolanum verbascifolium Solanaceae Potato tree SalvadoraTamarindus indica Fabaceae Tamarind TamarindoTaraxacum officinale Asteraceae Dandelion Diente de leónTecoma stans Bignoniaceae Trumpet bush Tronadora, Palo de ArcoTelauma mexicana Magnoliaceae None identified MagnoliaTilia occidentalis Tiliaceae Linden TilaTilia spp. Tiliaceae Linden TilaTilia vulgaris Tiliaceae Linden TilaTrigonella foenum-graecum Fabaceae Fenugreek seed LinasaTriticum durum egyptum Poaceae Kamut, wheat grass, sprouted None identified

whole leaf extractViola odorata Violaceae Sweet violet Violeta



Table 2. Commercial preparations used

Diabetea

Brickellia cavanillesiiCecropia obtusifoliaEysenhardtia polystachyaMedicago sativaOpuntia sp.Solanum verbascifoliumTaraxacum officinaleTecoma stans

Diabetesnat

Ibervillea sonoraeOpuntia sp.

Diabe-te

Solanum verbascifoliumOpuntiaMedicago sativaCecropia obtusifoliaBrickellia cavanillesiiTecoma stansEysenhardtia polystachyaTaraxacum officinale

Diabetil

Aloe veraBerberis sp.Briza mediaCecropia sp.Elettaria cardamomumTilia sp.

Diabetina Colombina

Brickellia sp.Crataegus sp.Geum urbanumMarrubium vulgare

Diabetifen

Cyamopsis tetragonolobusGinkgo bilobaTrigonella foenum-graecum

Dietopal

Opuntia ficus-indicaOpuntia lindheimeriOpuntia streptocanthaGlucotrinAmaranthus sp.Hymenaea courbarilOpuntia sp.

13 Flores

Caesalpinia pulcherrimaCasuarina equisetifoliaCordia boissieriCrataegus sp.Eucalyptus globulusChiranthodendron pentadactylonGnaphalium conoldeumJuniperus flaccidaTalauma mexicana

herbs; (2) licuados, a mixture of herbs, juices and foodsminced or blenderized; (3) dried herbs or mixturesof herbs taken as a hot or cold tea; (4) agua frescas, acold mixture of primarily one herb that is drunk as arefreshing beverage (sometimes found at fiestas andoften mixed with sugar or honey).

Subjects reported ingesting herbs in many ways; frommaking licuados every day for years from herbs grownin their back yard, to trying the newest herb they hadheard about (such as Neem or Noni) for a short period

of time. Herb use appeared to supplement, rather thanreplace standard medical therapy for diabetes.

Based on a review of the five major studies of South-west US herb use (Trotter, 1981; Moore, 1989; Kay,1996; Noel et al., 1997; Winkelman, 1989), five herbsappear to be part of the Southwestern US Hispanictradition, based upon identification in three or morestudies: Aloe spp. (Savila), Opuntia spp. (Nopal),Psacalium decompositum (Matarique), Tecoma stans(Tronadora) and Turnera diffusa (Damiana).

Tilia occidentalisViola odorata

Nature’s Sunshine Nopal Leaf

Opuntia streptocantha

Jounkins

Cassia angustifoliaAgastache mexicana

Nature’s Sunshine

‘Thyroid Activator’

form KC-X

Capsicum annuumChondius crispusCrataegus oxyacanthoides

Bob’s Red Mill Whole

Ground Flaxseed Meal

Linum

Quinoa

Alnus acuminataHaematoxylum basilettoHeterotheca inuloidesJuglans regiaJuliana adstringensJusticia spicigeraSmilax aristolochiaefolia

Tizana Betel

Chiranthodendron pentadactylonHaematoxylum brasilettoPassiflora alataTilia vulgaris

Neem

Azadirachta indicaTetohuxtleTetohuxtle

Noni

Morinda citrifolia (Noni). Indian Mulberry

Natu-Herb

Unknown

Tetohuxtle

Camellia sinensis

Nature’s Sunshine pH

GreenZone Powder

Chlorella regularisSpirulina platensisTriticum durumMedicago sativaAmaranthus sp.Hordeum

Nature’s Sunshine CoQ10 Plus

Ascophyllum nodosum + Laminaria digitataJuglans nigraNasturtium officinaleSmilax officinalis



Table 3. Probable effect on diabetes

Evidence of activity

Aloe spp. (Bordia, 1981)Cyamopsis tetragonoloba (Fariaset al., 1997; Srivastava et al., 1987)Equisetum spp. Vuorinen-Markkolaet al., 1993; Andrade-Cetto et al., 2000)Ginkgo biloba (Ajabnoor, 1990)Linum usitatissimum (Sanchez deMedina et al., 1994)Opuntia spp. (Soon and Tan, 2002)Trigonella foenum-graecum (Ajabnoor,1990; Perez et al., 1984)

Some evidence of activity

Allium sativum (Hitchcock et al., 1997)Azadirachta indica (Ajabnoor, 1990)

Brickellia spp. (Natural MedicinesComprehensive Database, 2004)Caesalpinia pulcherrima (Moore, 1989)Camellia sinensis (Chakrabarti et al., 2003)

Capsicum annum (Gomes et al., 1995)Cecropia spp. (Tandan et al., 1992)

Chlorella regularis (Ajabnoor, 1990)Citrus spp. (Ajabnoor, 1990)Croton cascarrilma (Roman-Ramos et al., 1991)Eucalyptus globulus (Revilla et al., 2002)Eysenhardtia polystachya (Gray et al., 2000)Gnaphalium conoldeum (Gray et al., 2000)Hibiscus sabdariffa (Kay, 1996)Hordeum (Ajabnoor, 1990)Hymenaea courbaril (Sachdewa et al., 2001)Ibervillea sonorae (Taylor, 2002)Juniperus flaccida (Alarcon-Aguilar et al., 2002)Medicago sativa (Lemay et al., 2002)Morinda citrifolia (Gray and Flatt, 1997)Smilax spp. (Frati et al., 1990)Solanum verbascifolium (Gray et al., 2000)Taraxacum officinale (Ageel et al., 1989)Tecoma stans (Cho et al., 2002; Lozoly-Meckesand Mellado-Campos, 1985)

DISCUSSION

This study sought to examine herb use among diabeticHispanic females. Herbal remedies were not used anymore frequently by participants who had worse diabeticcontrol (based on hemoglobin A1C levels), or who hadgreater severity of illness according to self-reporteddiabetes-related problems or symptoms. This is consistentwith a similar study of diabetic patients of CommunityHealth Centers in South Texas, which had a consider-ably larger sample size and found no difference betweenusers and non-users of herbal remedies and severity ofillness, measured by hemoglobin A1C levels, numberand severity of comorbid conditions, and frequency ofreported symptomology (Hitchcock et al., 1997).

The basic limitations of a study of this nature, andof examining the use of herbal remedies in general,involve determining what substances are actually beingingested, whether the substance has any potency inthe particular formulation or amount taken, and what

The use of diabetes-specific herbs was documentedin only seven (~7%) of the 104 medical charts reviewed,and included Opuntia, Aloe and ‘Diabetic Herbal Teafrom Mexico’. The use of all herbs (diabetes-specificand general) was documented in 16 (15.4%) medicalrecords. These include Gingko biloba, Kava, St John’sWort, Salvia, Valerian Tea, Flaxseed and Tea Tree Oil(Maleleuca alternifolia). No herbs were documented inthe pharmaceutical records of the same 104 randomlyselected diabetic patients. Pharmacists at both facilitiesindicated that they did not screen, monitor or discussherb use with patients.

Based upon a review of the similar studies, the herbsreported by study participants were categorized accord-ing to their likelihood to actively affect diabetes. Sevenherbs reported by participants have evidence of activ-ity to affect diabetes, including Aloe spp., Cyamopsistetragonloba, Equisetum spp., Gingko biloba, Linumusitatissimum, Opuntia spp. and Trigonella foenum-graecum. Another 25 identified herbs may possiblyaffect diabetes (Table 3).

No evidence of activity

Agastache mexicanaAlnus acumianata

Amaranthus spp.

Ambrosia spp.Ananas comosus

Apium graveolensArctostaphylos spp.

Ascophyllum nodosumBerberis spp.Briza mediaCassia angustifoliaCasuarina equisetifoliaChiranthedendron pentadactylonChondrus crispusCordia boissieriCrataegus spp.Cucumis sativusElettaria cardamomumGeum urbanumHaematoxylun brasilettoHeterotheca inuloidesJuglans nigraJuliana adstringensJusticia spicigeraKrameria greyiLippia albaMalus sylvestrisMarrubium vulgareMentha spicataPachycereus marginatusPassiflora alataPetroselinum sativumSpirulina platensisRorippa nasturtiumTamarindus indicaTilia spp.Triticum durum egyptumViola odorata



effects the herb may have. Some of the different herbsstudied have the same Hispanic name, for example‘hierba buena’, ‘gordolobo’ and ‘prodigiosa’; each His-panic name represents at least two different species. Inmost cases, the investigators had to rely on the manu-facturer’s labels for the remedy name, which often usedantiquated terms or synonyms of currently acceptednomenclature. It was outside the scope of this study tobotanically or chemically analyse the herbal material,so there is no definitive measure that an herbal remedycontained what the label claimed.

Although many of the herbs reported have potentialefficacy in treating diabetes, or result in adverse effectsor drug interactions, a review of the existing clinicalliterature suggests that the herbs reported in this studyare unlikely to have a significant effect on clinical out-comes in diabetes, either positively or negatively. Thisis particularly true given the manner in which herbsmostly appear to be used (rarely or intermittently, forshort periods of time, in small doses, or as a small frac-

tion of a mixture of proprietary herbs). And, while it isunknown what percentage of patients from the ran-domly selected medical charts use herbs, there was nosignificant difference in hemoglobin A1C values be-tween subjects interviewed and randomly reviewedpatient medical charts. There may be other reasons toask about and discuss herbs used by patients, i.e.adverse effects or interactions, but not necessarily fordiabetes alone.

Given the large number of herbs used by patients,and the wide variety of herbal remedies reported inthis study, and that only about 15% of medical recordsincluded documentation of herb use, clinical educationprograms are needed for physicians, pharmacists, ancil-lary staff and patients. Additionally, since most of theherbs documented were those in general usage (Kava,Valerian, Ginkgo) rather than herbs taken specificallyfor diabetes, clinical education efforts should encom-pass herbs in general use taken for a variety of con-ditions or reasons.

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Use of herbal remedies by diabetic Hispanic women in The southwestern United States