SQU Med J, February 2011, Vol. 11, Iss. 1, pp. 62-68, Epub. 12th Feb 11
Submitted 15th Aug 10
Revision ReQ. 27th Sept 10, Revision recd. 27th Oct 10
Accepted 10th Nov 10

1Department of Family Medicine & Public Health, Sultan Qaboos University Hospital, Muscat, Oman; 2Ruwi Health Center, 
Directorate General of Health Affairs Muscat Region, Ministry of Health, Oman; 3Al Hamra Health Center, Directorate General 
of Health Affairs Dakhiliya Region, Ministry of Health, Oman; 4Department of Pharmacology & Clinical Pharmacy, College of 
Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman, and 5Gulf Health Research, Muscat, Oman.
*Corresponding Author email: rkindi@squ.edu.om

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
 :مفتاح الكلمات

aBStract: Objectives: The use of complementary and alternative medicine (CAM) for diabetes mellitus is becoming 
increasingly popular; however, little is known about the prevalence of CAM use in patients with diabetes mellitus in 
Oman. The objectives of this study were to estimate the prevalence of use of CAM among diabetic patients in Muscat 
region, Oman, and to determine the types of CAM used as well as to identify the demographic features influencing the 
use of CAM. Methods: The study was performed from May to August 2009 on diabetic patients from 4 health centres in 
Muscat region. A total of 146 patients were interviewed. Information was obtained on demographics, and the prevalence 
and pattern of use of CAM. Results: Sixty two (42%) of the participants used CAM for the treatment of diabetes. Thirty 
(48%) were satisfied about its use and 27 (43%) intend to use it again. The only types of CAM used by participants in 
this study were herbs (n = 49, 79%), and/or food supplements (n = 7, 11%). Family and friends (n = 47/62, 76%) and/or 
traditional healers (n = 19, 31%) were the main source of information on CAM in the treatment of diabetes. There was 
no significant correlation between demographic characteristics and the use of CAM for diabetes. Conclusion: CAM is 
used widely for diabetes in Muscat region, Oman. Patients have strong faith in CAM in terms of effectiveness. Doctors 
should recognise this and be prepared to talk more freely with patients about its use and potential side effects.

Keywords: Complementary medicine; Alternative medicine; Complementary and alternative medicine (CAM); 
Diabetes mellitus (DM); Oman

Complementary and Alternative Medicine 
Use among Adults with Diabetes in Muscat 

Region, Oman
*Rahma M Al-Kindi,1 Muna Al-Mushrafi,2 Muna Al-Rabaani,3 Ibrahim Al-Zakwani4,5

CLINICAL & BASIC RESEARCH

ADVanceS in KnoWleDGe 
1. This study is the first in Oman to explore the use of complementary and alternative medicine (CAM) in patients with diabetes. It is the 

key for further research in this field with the hope of improving management of people with diabetes.
2 This study has shown how common the use of CAM is in Oman. 



Rahma M Al-Kindi, Muna Al-Mushrafi, Muna Al-Rabaani and Ibrahim Al-Zakwani

Clinical and Basic Research | 63

Oman has a long history of using traditional and herbal remedies; however, few studies have been conducted in 
the country.1,2,3 These remedies are supplied by 
traditional healers, or self-obtained, and are 
administered in the management of a wide variety 
of both acute and chronic conditions. Despite the 
extensive development of the health care system in 
Oman and the availability and accessibility of free 
health facilities and drugs, traditional medicine is 
still widely used. 

Traditional medicine, or complementary and/
or alternative medicine (CAM) refers to “health 
practices, approaches, knowledge and beliefs 
incorporating plant, animal and mineral based 
medicines, spiritual therapies, manual techniques 
and exercises, applied singularly or in combination 
to treat, diagnose and prevent illnesses or maintain 
well-being”.4 CAM has maintained its popularity 
in all regions of the developing world and its use 
is rapidly spreading in industrialised countries.5 
For instance, in Africa, 80% of the population uses 
traditional medicine to help meet their health 
care needs.6 In Europe, North America and other 
industrialised regions, over 50% of the population 
have used CAM at least once in their lives.7  

The use of CAM among diabetics is common. A 
recent review of 18 studies from 9 countries showed 
that the prevalence of CAM use among patients 
with diabetes varied from 17% to 72.8%. Most of 
the studies reviewed were conducted in developed 
countries and the majority of papers were derived 
from the USA and Australia.8 In developing 
countries, such as Saudi Arabia, 17.4% of patients 
with diabetes in Riyadh 9 and 30% in Mecca10 used 
some forms of herbs. In the United Arab Emirates, 
76% of patients with diabetes had previously used 
herbs and 38% were currently using some forms of 

CAM.11 In Bahrain, 63% of patients with diabetes 
had used CAM within the previous 12 months.12

Of all chronic diseases, diabetes mellitus has 
emerged as a major and growing health problem 
in Oman. The Oman National Health Survey of 
Diabetes, conducted in 1991, showed that the 
prevalence of diabetes is 9.75%, while the follow-up 
survey in the year 2000 showed an increase in the 
prevalence to 11.6% among adults over 20 years of 
age.13-15 The prevalence estimate of diabetes mellitus 
in Oman by the International Diabetes Federation 
(IDF) in 2010 is 13.4% and is expected to increase in 
the next 25 years.16 

This makes diabetes the second most common 
cause of morbidity in males and females above 
the age of 45 years and the fourth highest cause 
of death.17 To our knowledge, no studies have yet 
emerged from Oman on the use of CAM by patients 
with diabetes. Therefore, this study was conducted 
to determine the prevalence of CAM use among 
patients with diabetes mellitus in the Muscat region 
and to reveal the types of CAM most commonly 
used as well as the factors contributing to their use 
in terms of demographic characteristics and disease 
features. 

Methods
A multi-centric, cross sectional study was conducted 
over a 4-month period from May to August 
2009 in four health centres in the Muscat region 
namely Ruwi, Wadi Al-Kabir, South Mawaleh, 
and Al-Khoudh. Each of these health centres 
serves a population of approximately 500 patients 
with diabetes. The diabetic clinics in these health 
centres are well developed in terms of availability 
of a diabetic register, appointment system, trained 
family physicians and a wide range of modern 

3. This study should generate an open attitude to CAM among Western health professionals and encourage the development of guidelines 
and regulations on the use of CAM. 

4. This study should help to identify CAM practices and determine their safety and effectiveness. 

Application to patient care
1. Complementary and alternative medicine practices are commonly used, but not totally devoid of risk. 
2. This information needs to be disseminated to the public and health professionals by: a) educating and training health professionals about 

CAM and its popularity in our community; b) encouraging doctors to ask patients about their use of CAM and persuading them to talk 
about it. This would avoid delays in seeking medical treatment and further complications; c) encouraging patients to report side effects 
of CAM. 

3. Integration between Western medicine and complementary and alternative medicine could result in both being provided at the same 
health care facility. This would avoid the risks of negative CAM-drug interactions. 



Complementary and Alternative Medicine Use among Adults with Diabetes in Muscat  
Region, Oman

64 | SQU Medical Journal, February 2011, Volume 11, Issue 1

pharmacological anti-diabetic medications. 

The target population of this study was patients 
with diabetes mellitus attending primary health 
care facilities. All patients (N = 146) attending the 
diabetes or general clinics in these health centres 
during the study period were enrolled in the study. 
The following people were excluded: patients 
who did not speak Arabic or English; those with 
dementia or learning difficulties; those with no time 
to complete the questionnaire; people who visited 
the health centres for purposes other than patient 
care, and those who refused to give consent.

Face-to-face interviews were conducted by 
trained family medicine residents using a pre-
coded and pre-tested questionnaire that was 
developed by the authors based on a pilot study 
and previous similar studies to assess the use 
of CAM by patients with diabetes.9-12 The types 
of CAM used were defined based on the US  
National Center for Complementary and 
Alternative Medicine (NCCAM) categorisation 
of CAM.18 The questionnaire was translated into 
Arabic and the interview was conducted in Arabic. 
Inquiry was made into demographic characteristics 
and type and duration of diabetes. In addition, 
records were reviewed to determine the presence 
of complications and co-morbidities, treatment, 
and the status of blood glucose levels during the 
three months prior to the study. A glycosylated 
haemoglobin level of <7% was taken to reflect a 
controlled blood glucose level.

Participants were also asked whether they 
had used CAM in general, and in particular for 
the treatment of diabetes. Among users of CAM, 
detailed information was obtained on: CAM use 
during the previous year; current use; type and 
frequency of use; source of information about 
CAM; extent of satisfaction and side effects (if 
any); use with prescribed medication/s; whether 
information on CAM use had been given to the 
treating physician, and intention of using CAM 
again. Finally, interviewees were asked to give 
their opinion on the safety and efficacy of CAM 
compared to modern medicine. 

Descriptive statistics were used to describe the 
data. For categorical variables, frequencies and 
percentages were reported. Differences between 
groups (CAM status, yes/no) were analysed using 
Pearson’s χ2 tests (or Fisher’s exact tests for cells 
less than 5). For continuous variables, mean and 

standard deviation were used to present the data 
while analysis was performed using the student’s 
t-test. An a priori two-tailed level of significance 
was set at the 0.05 level. Statistical analyses were 
conducted using STATA, Version 11.0 (STATA 
Corporation, College Station, TX, USA).

Informed consent was obtained from all 
participants before the interview. Ethical approval 
for the study was granted in 2009 by the Medical 
Research & Ethics Committee of the College of 
Medicine & Health Sciences at Sultan Qaboos 
University, Oman.

Results
This study included a total of 146 patients with 
diabetes mellitus type 1 (n = 6, 4%) and type 2 (n = 
140, 96%). The majority of patients (n = 136, 93%) 
were Omani nationals. More than half of these 
patients were women (n = 84, 58%), and in the age 
group 46 to 65 years (n = 82, 56%) [Table 1].

The duration of diabetes ranged from 2 months 
to 40 years (mean 8.48 ± 6.5 years). Nearly a third 
of the patients (n = 56, 38%) reported the presence 
of one or more complications including retinopathy  
(n = 21, 14%), ischaemic heart diseases (n = 18, 
12%), nephropathy (n = 17, 12%), neuropathy (n = 
11, 8%), and transient ischaemic attacks and strokes 
(n = 4, 3%). Co-morbidities were reported by 105 
(72%) of the patients including hypertension (n = 
76, 52%), dyslipidemia (n = 17, 12%), gastrointestinal 
diseases (n = 14, 10%), joint diseases (n = 13, 9%) 
and mood disorders (n = 44, 30%). A review of the 
records for these patient for the 3 months prior to 
the study revealed that 109 (75%) of the patients had 
uncontrolled blood glucose levels.

Table 1 reveals that users and non-users of 
CAM for the treatment of diabetes are comparable 
in regard to their demographic and clinical 
characteristics. The ever use of CAM was reported 
by 76 (52%) of patients. A total of 42% (n = 62) 
of those who had ever used CAM had used it 
specifically for the treatment of diabetes. Just over 
a quarter of these patients (n = 41, 28%) had used 
CAM within the last 12 months and 28 (19%) were 
current users. The main types of CAM used were 
herbal remedies (n = 49/62, 79%) and/or food 
supplements (n = 7/62, 11%). Most herbal remedies 
were in mixed/compounded forms and more than 
half of the patients (n = 36/62, 58%) had used 



Rahma M Al-Kindi, Muna Al-Mushrafi, Muna Al-Rabaani and Ibrahim Al-Zakwani

Clinical and Basic Research | 65

several types of herbal remedies. “Harmel” (Rhazya 
stricta) (n = 6/62, 10%), fenugreek (Trigonella 
foenum, Arabic “helba”) (n = 5/62, 8%) and black 
seeds (Nigella sativa) (n = 4/62, 6%) were the most 
commonly used.

Among those who used CAM for the treatment 
of diabetes, 48% (n = 30) expressed satisfaction with 
its use and 44% (n = 27) stated that they intend to 
use it again. In addition, 23% (n = 14) perceived 
CAM as more effective than modern medicine 
and 27% (n = 17) as safer. Interestingly, 45% (n = 

28) of the participants were taking herbal remedies 
concurrently with their Western anti-diabetic 
medications and only 13% (n = 8) of them had 
informed their treating physicians about CAM use. 
The main source of information on CAM for the 
treatment of diabetes was family and friends (n = 
47, 76%) and/or traditional healers (n = 19, 31%). 
The self-reported rate for adverse events associated 
with CAM use was 13% (n = 8). 

Table 1: General characteristics of the study participants stratified by use of complementary and alternative medicine

Characteristics

Total frequency 
(N = 146)

Use of complementary and alternative medicine in 
diabetic patients P value

Yes
n = 62 (42%)

No
n = 84 (58 %)

Age, n (%)

21–34
35–45
46–55
56–65
66–88

8 (5%)
32 (22%)
38 (26%)
44 (30%)
24 (16%)

2 (3%)
16 (26%)
18 (29%)
18 (29%)

8 (13%)

6 (7%)
16 (19%)
20 (24%)
26 (31%)
16 (19%)

0.586

Sex, n (%)

Female 84 (58%) 32 (52%) 52 (62%) 0.214

Marital status, n (%) 

Married 123 (84%) 52 (84%) 71 (84%) 0.915

Education, n (%) 

Illiterate 
School 
Post-school 

63 (43%)
58 (40%)
25 (17%)

23 (37%)
30 (48%)

9 (15%)

40 (48%)
28 (33%)
16 (19%)

0.185

Nationality, n (%) 

Omani 136 (93%) 60 (97%) 76 (90%) 0.190

Diabetes mellitus (DM) type, n (%)

DM Type 2 140 (96%) 60 (97%) 80 (95%) 1.000

Duration of DM, n (%)

<5 years
5-7 years
8-10 years  
>10 years

42 (29%)
34 (23%)
37 (25%)
33 (23%)

21 (34%)
9 (15%)

17 (27%)
15 (24%)

21 (25%)
25 (30%)
20 (24%)
18 (21%)

0.184

Control of blood glucose (<7% HbA1c), n (%)

Controlled 37 (25%) 14 (23%) 23 (27%) 0.510

Complications* present, n (%)

Yes 56 (38%) 22 (35%) 34 (40.48) 0.540

Concurrent diseases present, n (%)

Yes 105 (72%) 47 (76%) 58 (69%) 0.369
* Complications include retinopathy, nephropathy, neuropathy, ischaemic heart diseases, transient ischaemic attacks and stroke. 



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Region, Oman

66 | SQU Medical Journal, February 2011, Volume 11, Issue 1

Discussion
The present study has shown that 42% of the diabetic 
patients had used CAM in the treatment of diabetes 
and 28% had used CAM in the previous 12 months. 
This is comparable with other similar studies in the 
Gulf States such as Saudi Arabia (30%),10 the United 
Arab Emirates (38%)11 and Bahrain (63%)12 as well as 
well as in the USA (73%),19 and India (68%),20 but it 
is higher than in Australia (24%) and the UK (17%).21 
This variation can be due to the use of different 
CAM definitions and the different timeframes of 
the studies as well as to different cultures. In our 
study, the types of CAM used were defined based 
on the NCCAM categorisation of CAM.18

There was no significant association between the 
use of CAM and the socio-demographic or clinical 
characteristics of the participants. Furthermore, 
the use of CAM was not associated with either 
blood glucose level, glycosylated haemoglobin 
A1C control or the presence of complications 
or concurrent illnesses. This could be due to the 
small sample size and the fact that the participants 
were health centre patients. This is particularly 
important as patients in the community may be 
using CAM more frequently and the way they use it 
may be different. The common types of CAM used 
users were herbal remedies and food supplements. 
The composition of most of these local remedies is 
not known as they are passed on from generation 
to generation and purchased ready made from the 
traditional healers or market (souk) outlets. Most of 
the patients had listed a variety of herbal mixtures 
and a few specified the name of the herbs used like 
harmel, fenugreek, and black seeds. The number 
of people taking herbal and modern medicines at 
the same time was high. The potential for adverse 
interactions with modern medicines is therefore 
very likely. This issue needs to be recognised by 
physicians to ensure that patients are not putting 
themselves in unnecessary danger. An appreciable 
number of people reported adverse effects while 
taking herbal products; however, it is almost 
impossible to establish causality because most of 
them took mixed herbs and the survey relied mainly 
on their recall.

Participants relied heavily on family and friends 
for advice on CAM use. Health education on this 
matter should be simultaneously provided to 
patients and their families. Moreover, education 

is recommended to inform their doctors about its 
use since the majority of patients did not inform 
their doctors, while simultaneously almost half 
expressed satisfaction with CAM use and intended 
to use it again. Patients may be worried regarding 
the negative attitude of doctors towards the use 
of CAM so they do not inform their doctors 
about it. Therefore, a more positive attitude from 
doctors may encourage patients to talk more freely 
regarding their use of CAM.

Participants had a strong faith in herbal 
medicines with regard to their effectiveness and 
safety. Nearly 25% of respondents indicated that 
CAM is more effective and safer than modern 
medicine in treating diabetes. This result will have 
important health implications if confirmed on a 
larger sample. Over-reliance on ineffective herbal 
remedies could lead to people either refraining 
from using or delaying the use of more effective 
modern medicine. This study also shows that CAM 
users have higher expectations of CAM than they 
do of conventional therapies. Therefore, physicians 
should recognise their patients’ underlying desire 
for improving their health status and be able to 
advise patients on the use of CAM.

Faith in CAM use is probably part of national 
heritage. These products have been used for 
generations with no apparent harm. This view is 
reinforced by family and friends who are the main 
influences on respondents’ decisions to use CAM. 
This, however, is not culturally unique as other 
studies in the region have shown that family and 
friends are intensely involved in decision making 
regarding the use of herbal medicine.9,11 Many 
researches have studied the anti-diabetic effects 
of some herbs and plants. However, the safety and 
efficacy of these herbal treatments are still to be 
determined.22 Patients may be putting themselves at 
risk by the use of these treatments.23 Some herbal 
products contain powerful substances that can be 
toxic either alone or in combination with other 

medications.24 The most important risk is that 
CAM is used as a true alternative to conventional 
treatments for serious medical conditions. In 
addition, there is no control over the quality of these 
products, which can be easily purchased in special 
outlets in the market (souk). Herbal remedies are 
widely considered to be inexpensive, but this is 
often not the case. This specific aspect of CAM use 
needs to be studied in a proper clinical setting.



Rahma M Al-Kindi, Muna Al-Mushrafi, Muna Al-Rabaani and Ibrahim Al-Zakwani

Clinical and Basic Research | 67

With the increasing importance of CAM in 
modern health care, medical and nursing education 
should include information about complementary 
practices.25 Physicians will be increasingly expected 
to address issues related to CAM use, but may not 
be able to become knowledgeable about all CAM 
practices. However, they can apply the principles of 
evidence-based medicine to CAM as to any area of 
health care.26 Physicians can search the published 
medical literature and evaluate the applicability of 
CAM for specific patient problems. 

The study has several limitations. The real 
percentage of CAM use in the treatment of diabetes 
might be found to be higher than that reported 
if the duration of the study were extended, and 
especially if extended to the community level. This is 
particularly important as patients in the community 
may be using clinical services less frequently and the 
way they use CAM may be different. This study was 
conducted in only one region and the results may 
not be generalisable to diabetic patients in other 
regions of Oman or to the entire country.

In addition, this study did not investigate 
the objective effectiveness of CAM on diabetes, 
such as showing that patients’ blood glucose was 
not controlled on their conventional therapy, 
but became controlled when CAM was added 
or substituted. Further research will be required 
involving many regions and to obtain data on any 
health benefits achieved through CAM usage. 

Conclusion
This study found out that many diabetic patients 
used CAM and most of those patients used herbal 
remedies. Family and friends played a significant 
role as sources of CAM information. Many patients 
did not inform their doctors about CAM use, 
taking them simultaneously with anti-diabetic 
medications, and had the intention to use them 
again. Doctors should recognise that CAM is widely 
used by diabetic patients and should appreciate that 
these medicines can cause adverse effects. Doctors 
should therefore be prepared to question their 
patients and try to encourage them to talk about 
their use of CAM as it may affect the outcome and 
the management of their disease.

c o n f l i c t o f i n t e r e s t
The authors reported no conflict of interest.

a c k n o w l e d g m e n t

The authors are grateful to Dr Randa Yousif, for her 
constructive review and comments.

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