In the current literature, reasons for CAM use are largely based on experience with adult populations. Reasons include dissatisfaction of patients with the effectiveness of conventional treatments (21
), the side effects of conventional therapies (25
), the perception that conventional practitioners communicate and interact less effectively than their complementary counterparts (25
), the need for a sense of control (26
), personal identification with the philosophical underpinnings of CAM (28
), the perception that CAM is natural and, therefore, safe (12
), and a belief that CAM is effective (29
). However, these theories may not be directly transferrable to parent or guardian decision-making for children and adolescents with T1DM, for whom the use of insulin is an absolute treatment required to avoid death or serious complications such as diabetic ketoacidosis.
We reported on the use of CAM in 195 children diagnosed with T1DM and followed in a Canadian tertiary paediatric diabetes centre. The present article is one of the largest surveys and, to our knowledge, the only Canadian study exploring the use of CAM in children with diabetes. The frequency of CAM use (excluding vitamin and mineral use) determined in the present study (24%) is comparable with reports in other populations of children with T1DM (6% to 43%) (16
) and other Canadian general paediatric populations, which have varied from 11% to 24% (25
). Some of the wide variation reported in frequency of use can be explained by the definition of CAM used. This is easily illustrated by our findings: 47 users (24%) when excluding the use of vitamins and minerals versus 110 (56%) when including these supplements.
In earlier studies, factors inconsistently found to influence use of CAM in children have been ethnicity (from cultural beliefs) (34
), the educational level of parents (16
), older children (17
) and the use of CAM by parents (1
). In the current report, information about ethnicity or parental use of CAM was not collected. In contrast to previously cited studies, the education level of parents was not found to be associated with CAM. This last observation may be explained by increased accessibility of information to a wider population through use of the Internet compared with an earlier Canadian study by Spigelblatt et al (25
). However, we did find, similarly to others (17
), that children who used CAM were older than children who did not use CAM.
In the present study, all subjects continued to use insulin even when opting for a trial of CAM. This finding is in concordance with the study by Dannemann et al (16
), in which the parents of children with T1DM using CAM did not question the need for insulin. When accepting this, parents may expect CAM to be less helpful and, therefore, refrain from using it. Two-thirds of parents using CAM subjectively stated an improved quality of life from the use of CAM. This is a similar percentage observed by Dannemann et al (64% in their sample). Unfortunately, in both studies, this improved quality of life was assessed by family perception (single question) rather than through formal, more reliable and valid quality-of-life measurements. A recent study specifically designed to examine the relationship between quality of life measured with the Pediatric Quality of Life Inventory (PedQL) questionnaire and CAM use in children with T1DM (17
) found no overall association between CAM use and quality of life. However, a subanalysis revealed a positive association between use of CAM diets and quality of life, but a negative association between supplements or stress-reduction therapies and quality of life. These authors also observed that smaller studies usually find no association with CAM and quality of life, in contrast to larger studies (more than 500 participants), which often report an association between poorer quality of life and CAM use.
The most common CAM therapies reported in the present study were vitamins and minerals, herbal therapies and dietary supplements. In our clinic, it is very common to suggest to patients that they use vitamins when we determine that they are not meeting their required daily dietary intake of foods from certain food groups as per the Canadian dietary recommendations. Thus, in these cases, recommended vitamin use would not be considered by the health care team and the family as using a form of CAM to manage the patient’s diabetes. The rate of use dropped from 56% to 24% when the use of vitamins was excluded from our definition. This illustrates the need to be specific in the definition used when comparing reports on CAM use because it has an impact on rates, and may explain some of the wide variations found in different reports.
As with mainstream treatments, CAM therapies have significant potential for adverse effects and drug interactions, some of which may be potentially serious (18
). There is a distinct possibility that families using CAM for their children may not inform their paediatrician or family practitioner of this use. There is some information emerging regarding parent or guardian communication with their paediatrician or primary care physician about the use of CAM. A recent study of CAM use in children (37
) found that 53% of the parents surveyed wished to discuss CAM with their paediatrician and 36% reported that they had discussed it with their child’s physician. In another study (38
), 40% to 50% of paediatric CAM users told their physicians about it directly. In addition, a survey of paediatricians (39
) revealed that 87% had been asked about CAM by a patient or parent in the three months before they were surveyed for that study. The authors mentioned that paediatricians recognize that many patients were interested in using CAM therapies, but were not comfortable discussing or recommending CAM therapies to their patients. If a child’s parents do not tell their doctor about CAM use, there is a potential risk for an adverse outcome. Therefore, it is important for the treating physician to be aware of CAM use, and to foster an open and trusting relationship with the family to avoid undesirable CAM interactions with the current treatment. Most of our clinic population had not informed their diabetes team about the use of CAM. Our study showed that medical professionals were still the most frequently sought sources of information about CAM use. This should be regarded as an opportunity to ensure the safety of patients who are considering the use of CAM.
For most parents, the use of CAM was determined to be an effort to improve control of the patient’s diabetes, or to prevent and curb complications in diabetic management. In contrast, improved metabolic control was not a reported benefit of the use of CAM. Our results showed that CAM was used as a supplement, rather than as a substitute, for insulin therapy. Again, these findings were similar to those of Dannemann et al (16
The present study did have limitations. The small number of individuals who used CAM in the current sample makes the overall generalizability of the findings somewhat limited. As with any self-reported survey, there may be a selection bias in which those who chose to participate may not be representative of the whole population. Although the questionnaire was anonymous, individuals who would not disclose use of CAM with their diabetes care team may have been less likely to complete the survey. Another confounder is that parental report would not have yielded all of the correct information about adolescent use of supplements or CAM. In addition, the design of our questionnaire did not distinguish the purpose of the use of multivitamins: for general health, as recommended by a diabetes team dietitian, or used in the context of CAM. To maximize the response rate and maintain the anonymity of the questionnaires, we did not collect information about the child’s ethnicity or objective measures of metabolic control. We also could not cross-check information about medical history or outcomes with the child’s chart. Finally, we did not include questions about parental use of CAM, which has been found to be a predictor of CAM use in children (1
Investigation of the use of CAM in children and adolescents with T1DM is important for a number of reasons. First, information derived from the present survey provides a better description of CAM use in children and adolescents. Second, it is very important that diabetes care teams enquire routinely, in a nonjudgemental manner, about CAM use in children and adolescents with T1DM, so that families feel at ease sharing their thoughts and beliefs with them. In addition, information about CAM use in the present population can be used to monitor patients who use CAM in terms of both benefits and side effects of these therapies. Finally, parents need to be reminded that very little research has been conducted to determine the efficacy, effectiveness and safety of many CAM therapies.
The use of CAM in children with T1DM is relatively common. Greater insight into the influences of CAM in the management and treatment of patients with T1DM could be achieved through assessment by diabetes care teams on the use of CAM in children with T1DM, and monitoring for any potential positive or negative effects. Similar to assessment of medication use or allergies, assessment of the use of CAM should be part of the routine evaluation of children with T1DM and any other chronic disease.