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Herbs, Prayer, and Insulin: Use of Medical and Alternative Treatments by a Group of Mexican American Diabetes Patients
METHODS: Following a descriptive qualitative design, a convenience sample of 43 low-income Mexican Americans with type 2 diabetes were interviewed. We analyzed interview transcripts for alternative treatments named, patterns of use, evaluation of those treatments, and the use of biomedical approaches. We crosschecked the results for interrater reliability.
RESULTS: Herbs were mentioned as possible alternative treatments for diabetes by 84% of the patients interviewed. However, most had never or rarely tried herbs and viewed them as supplemental to medical treatments. Most said prayer influences health by reducing stress and bringing healing power to medicines. None used curanderos (traditional healers) for diabetes. Most actively used biomedical treatments and were less actively involved in alternative approaches. Statistical tests of association showed no competition between biomedical and alternative treatments, and alternative treatment activity tended to be significantly lower than biomedical. Most study participants emphasized medical treatment and only used alternative treatments as secondary strategies. Those patients very actively using alternative approaches also tended to be very actively using biomedical methods; they were using all resources they encountered.
CONCLUSIONS: Traditional attitudes and beliefs were not especially important to the patients in this study and presented no barriers to medical care. For these patients, it also cannot be assumed that belief in alternative treatments and God’s intervention indicate fatalism or noncompliance but instead require consideration of individual treatment behaviors.
Alternative medicine has increasingly become the subject of medical research, in part driven by a concern that such treatments, despite their apparent innocuousness, may harm patients by exposing them to unknown dangers or by drawing them away from medical treatments.1-7 As many as 1 in 3 people in the United States report using alternative treatments, most often for chronic illnesses such as diabetes.8 More than 400 herbal remedies for diabetes have been reported worldwide.9-11 Mexican Americans, who have rates of type 2 diabetes at 2 to 3 times that of the general population,12 also show high interest in alternative medicine, with as many as 67% reportedly using folk remedies.13-15
Although many clinicians worry that alternative treatments may present barriers to effective health care for Mexican American patients with diabetes, research does not support this concern. Several previous studies have focused on alternative treatment use by Mexican Americans,13,14,16-21 but these treatments were not shown to be highly prevalent or of great importance to this group. For example, although many studies have examined use of herbal remedies,22-26 the traditional healers called curanderos,13,17,27 and health-related religious beliefs,4,28-32 most merely report the frequency of these beliefs and practices, without explicitly examining how patients use and evaluate such treatments. There has not been careful consideration of the relative importance of these approaches to the health care of individuals or of how their use affects the utilization of biomedical treatments.
Since noncompliance with medical care is of great concern for physicians of patients with type 2 diabetes,33-36 the question of whether there is competition between biomedical and alternative treatments for this group is an important one. However, a great deal of previous research by anthropologists and other social scientists indicates that this may not be a realistic concern. It has been consistently found that in everyday practice people draw on different health systems simultaneously, using various treatments as complimentary rather than competing alternatives.8,14,37-50 Thus, to understand the role that alternative treatments may play in managing diabetes, it is necessary to not only explore whether those therapies are known and used, but also how their use is integrated with use of biomedical approaches.
We report on a descriptive study of a group of Mexican American patients with type 2 diabetes. We examined how they say they use and evaluate alternative treatments and how they integrate them with conventional medical care.
Methods
Patient Selection
In 1994 and 1995 we discussed alternative treatments for diabetes with a convenience sample of 43 self-identified Mexican American patients. These patients were visiting at 2 public clinics serving low-income patients in San Antonio and Laredo, Texas, for type 2 diabetes. We included patients who had type 2 diabetes for at least 6 months before the interview, had no major impairment because of diabetes, and gave informed consent to be interviewed in their homes. Fifteen patients were recruited while waiting to see internal medicine physicians at the San Antonio clinic. The rest were participating in patient education trials as part of a larger project being conducted by the Texas Diabetes Institute. Nineteen of these were part of a diabetes patient education trial at the San Antonio clinic, and 9 were part of an evaluation of a provider education trial at the Laredo clinic.
Data Collection
We conducted in-depth open-ended interviews following an interview guide of standardized questions. Patients were encouraged to answer in their own words with as much detail as they wished. To facilitate cross-case comparisons, every critical question was asked of all participants. The interviews were conducted in patients’ homes in the language of their preference, lasted approximately 2 hours each, and were tape-recorded and transcribed. The first author (LMH) performed translations from the original Spanish.
The interviews addressed the patients’ personal experiences with diabetes, self-care behaviors, and individual perceptions regarding their health status. Questions about their use of alternative treatments included: Have you ever used or heard of any other kinds of treatments for diabetes? Any home remedies or things like herbs or curanderos? Have you tried them? Do you think they help? Do you think that religion or your spiritual life can affect your health? Do you ever pray about your health or your diabetes? Do you think it helps?
Data Analysis
We indexed all field notes and transcripts by topic and established a filing and retrieval system. We then created a database with variables grounded in open-ended responses to relevant questions. We analyzed this data using SPSS software.51 We also established a method for displaying interview data, building initial matrices of blocks of text (quotations and summations) for each patient that included comments about treatment behaviors and evaluations of their effects. Next, we identified trends and patterns among cases, which we summarized into higher level matrices with the participants grouped by types and patterns of treatment.
We crosschecked all phases of analysis in conference sessions during which the research team reached consensus about applying coding categories and addressed any anomalies or discrepancies. Interrater reliability was established through a second researcher recoding 50% of the case material, validating consistency in coding and classification procedures.
Results
Patients ranged in age from 29 to 69 years with a mean age of 53.9 years. Like most patients in the public clinics from which they were recruited, they were mostly of low-income and low-educational levels, with nearly two thirds unemployed, a mean annual household income of approximately $12,500, and an average of 8.1 years of schooling. Approximately half of the sample chose to be interviewed in Spanish. Approximately half were men, half had diabetes for 6 years or longer, and half had good blood glucose control at the time of the interview. Classification of a participant’s level of glucose control was based on review of medical records from the past year. For glycosylated hemoglobin (Hb A1C), a level of 7.5% or lower was considered good, 7.6% to 10.0% was fair; and higher than 10.0% was poor. If an Hb A1C result was not available, the fasting glucose level was used, with lower than 180 mg/dL considered good, 180 mg/dL to 250 mg/dL fair, and higher than 250 mg/dL poor (Table 1).
Herbal Treatments
When asked if they knew of any treatments for diabetes besides diet, exercise, and medications, 84% of the participants (36/43) said they had heard ofusing herbs to treat the disease (Table 2). The herbs mentioned most often were nopal (prickly pear cactus), 39%; aloe vera, 31%; and nispero (loquat or chinese plum), 17%. However, more than a third of those who mentioned herbs named no specific herb but merely said they had heard herbs could be used (Table 3).
The nopal or prickly pear cactus (opuntia) is a very common plant in South Texas and is a common food item in the region. Its leaves are lightly cooked and mixed with eggs or eaten as a vegetable side dish. Some people in our study reported having increased these dietary uses of nopal as an adjunct to their treatment for diabetes. Others described making a licuado (a drink mixed in an electric blender) out of raw nopal leaves and water; some also added raw aloe vera to this mixture. Most people who described this preparation said they felt it had a positive effect on lowering blood sugar, but some said it had a bitter taste and did not continue to take it after trying it once or twice.
Nispero or loquat (eriobotrya japonica) is also a common plant of the region. It is a large shrub with long leathery leaves that produces clusters of sweet yellow fruit in the spring. Its leaves are brewed into a strong tea that some patients said they drank up to 3 times a day and found helped lower their blood sugar.
Frequency of Herb Use
Very few of our subjects reported using herbs with any regularity (Table 2). Nearly two thirds who named herbs said they had never tried them or had only tried them once or twice, while less than a third said they had regularly used them in the past. Only 9% said they currently use herbs regularly.
Not surprisingly, several of those reporting using herbs regularly felt the herbs helped control their blood sugar. One patient explained his belief that herbs can help in these terms: “What sustains our bodies is what we extract from the earth. So, I mean, what’s wrong with medicinal herbs if they’re doing good?”
The majority of patients, however, were more skeptical about the value of using herbs:
“I’ve heard of them, but I don’t really care too much about them. There’re a lot of people that say herbs can help with the diabetes, but I don’t like to try them. I might be allergic to them or something, or I might get worse off than I am. I’m not gonna take a chance and take something like that.”
“I’ve heard of some [herbs], but I never used any of them. My mother tried them, but I don’t know. I just don’t believe in all that. It’s like remedies for older people.”
“People tell me about [teas], but I haven’t tried any yet. I just take my medicine. If they can’t cure you with medicine, you know, the earth ain’t gonna help you. I don’t want to mix up anything with my medicine.”
Even when people have tried herbs for their diabetes, it cannot be assumed that they believe in their efficacy. Nearly half of those who had tried herbs said they did not help with diabetes or may even have been harmful. In contrast, less than a third felt herbs had a noteworthy positive effect on their illness (Table 2).
Prayer and Curanderos
When asked if they thought God or prayer helped their diabetes, 77% (17/22) said yes (Table 2). It is important to consider the specific ways they believed prayer helps. Most did not think prayer could have a direct impact on their diabetes but instead thought it helped indirectly by reducing their stress and anxiety. A typical comment was: “I ask God to help me with my diabetes. I pray for Him to give me the strength to go on. It makes me feel more tranquil, calmer.”
Several patients (27%, 6/22) said God had a direct influence on their disease management, but this did not excuse them from vigorously pursuing medically recommended treatments. Contrary to the common assumption in the medical literature, we found no patient who thought prayer or God’s help could replace medical treatment. Instead, these patients saw medical treatment as the vehicle through which God would heal them. As one patient explained:
“You have to ask God’s help, you have to pray. God gives the means. He gives us doctors and the medicine, so that they can help us. But, we can’t leave everything to Him. We have to take hold of the means. See, it’s the medicine, but first of all it’s God, and then the medicines. Have faith in what the doctor prescribes.”
Similarly, we found no evidence that these patients turned to traditional healers, such as curanderos, for their diabetes. We did not find a single case of a patient having consulted a curandero for diabetes management. The use of curanderos for any condition among those we interviewed was very rare: Only 3 had ever used a curandero, and all had done so only once and only for diseases other than diabetes (Table 2). Our participants were unanimously skeptical about curanderos:
“I’d rather take the medicine from the doctor than go to the curandero. I don’t believe in them. I think the doctor is best.”
“You have to believe in them (curanderos) for it to work, and I really don’t have trust in them.”
“I wouldn’t have any faith in those guys to tell you the truth. I just don’t think they work. ‘Curandero!’” (Laughs)
Interaction Between Alternative and Biomedical Treatments
We have seen no evidence of any conflict or competition between alternative and conventional treatments among these patients. On the contrary, their comments indicate they may give priority to biomedical regimens over alternative ones. To test this observation, we compared each patient’s level of involvement with biomedical and alternative treatments. On the basis of the individual’s self-reports of treatment behaviors, we classified their level of activity in each type of treatment as high, medium, or low. A scoring method was devised that produced composite scores, reflecting level of activity in each of 3 dimensions of each treatment type. Two researchers independently classified all cases; any discrepancies in classification between them were resolved in meetings of the entire research team.
We scored the level of biomedical activity as follows: Three points were given for taking medications as prescribed, for following a prescribed diet, and for exercising regularly. Two points were given for taking medication but not precisely as prescribed, for following a diet irregularly, and for exercising intermittently. One point was given for having stopped taking medication, for not instituting any dietary changes, and for not exercising.
We scored the level of alternative treatment activity as follows: Three points were given for identifying 2 or more alternative treatments, for currently using an alternative treatment, and for positively evaluating the effect of an alternative treatment on diabetes. Two points were given for listing at least one alternative treatment, for reporting either past or future but not current use of such treatments, and for neutrally evaluating the effectiveness of alternative treatments. One point was given for listing no specific alternative treatments, for not having tried any and not planning to do so, and for negatively evaluating the impact of alternative therapies.
Activity scores for each type of treatment ranged from 3 to 9. Overall activity level was classified as follows: 3 to 4.5 was low, 4.6 to 7.5 was medium, and 7.6 to 9 was high.
The scores for level of activity in biomedical and alternative treatments are summarized in Table 4. Very few patients were inactive in pursuing biomedical treatment, while nearly a third were very actively pursuing it. Although the majority were doing so imperfectly, their interest and intention to follow biomedical regimens was clear. In contrast, the level of involvement with alternative treatments was notably less pronounced. Nearly half were classified as having low activity in alternative treatments, and the rest were divided between high and medium activity levels.
If alternative and biomedical treatment strategies were in competition for these patients, one would expect to see a strong negative correlation between these variables. However, this was not the case (Figure). In fact, the correlation coefficient of r=.155 shows a small positive correlation. That is, people that are active in alternative treatments are somewhat more likely to also be active in biomedical treatment. Furthermore, the paired Student t test shows that, on average, individuals have .338 lower alternative activity scores than biomedical scores and that this is a statistically significant difference with a 2-tailed P value of .017.
Thus, rather than using alternative treatments instead of biomedical treatments, we see the opposite: Our participants were more likely to choose biomedical treatments over alternative methods. For those individuals who were highly engaged in alternative treatments, there was a tendency to also be quite active in biomedical treatments. It seems that patients who are not very interested in biomedical treatments for their diabetes are not very interested in any kind of care. Those who are very interested in alternative treatments seem to be involved in a process of actively seeking solutions to their diabetes, drawing on whatever resources they encounter. The following quotes illustrate this attitude:
“I’ve always gone with what the doctors give me. And now I just want to get off insulin. I’m tired of it. And I’m gonna try as much as I can, whatever they tell me.”
“Herbs are good, but they have to be under medical assistance with an MD, so he can prescribe the medication you need to help you along.”
Discussion
Our study is unique because we not only documented the variety of alternative treatments a group of Mexican American patients were aware of for type 2 diabetes, but also explored how they thought about and used these treatments. We found that although most of these patients could list a variety of herbal treatments for the disease, few reported regularly using them, and few said they found them very effective. Many who did use herbal treatments said they did so only occasionally, and none said they had replaced medical regimens with alternative treatments. None had used curanderos for their diabetes, and although many prayed about their illness, this was done in conjunction with medical treatment, not in its place.
Although the understanding of and compliance with conventional diabetes regimens of many of these patients may be less than optimal,52-54 we found no reason to attribute these limitations to their use of alternative treatments and their religious beliefs and practices. Such approaches are clearly viewed by these patients as supplemental to biomedicine and are not given primary emphasis. Most expressed the attitude that alternative therapies may not help much but probably will not hurt, as long as they are used in conjunction with what medical providers recommend.
It should also be noted that the natural evolution of type 2 diabetes is such that it may progress and remain uncontrolled despite a patient’s best efforts to follow medical advice.55 In this context, our findings suggest that many patients who try alternative therapies may be highly motivated to control their diabetes and engaged in an earnest effort to try all methods available to them. The patients we interviewed were not passively relying solely on alternative treatments but instead pursued several treatment strategies simultaneously.
Furthermore, there is some evidence of the clinical efficacy of the 2 herbs most commonly mentioned by these patients. In laboratory studies, both nopal and nispero have been found to have notable hypoglycemic effects. Studies of both patients with diabetes and of laboratory animals with induced hyperglycemia have reported that these substances decrease serum glucose levels from 17% to 46%.56-62 Although this research area is not well developed, it is possible that these herbs do in fact help reduce glucose levels.
We also found that the role of religion in the management of these patients’ diabetes was not in opposition to their medical treatment but very much in its support. Patients who use prayer and religion to help with illness management are often portrayed in the medical literature as fatalistic, abdicating responsibility for their health care to a higher power, and failing to take care of themselves. Although many of our participants said God is important in controlling their diabetes, they felt God works through the clinician and medications, not in place of them.
Limitations
Our study was designed with the goal of developing a thorough understanding of the treatment concepts and practices of the participants. It was not designed to produce generalizable findings. Our findings should not be taken to refer to a broader population but should be viewed as a window on how a group of individuals think about and use these treatment systems. We have chosen to note percentages in reporting our findings to show the distribution of a concept or behavior within our study group. This should not be taken to imply an expected prevalence in a larger population.
It also must be emphasized that these are tentative findings. They are based on a relatively small convenience sample drawn from patients already receiving clinical care or participating in education intervention trials. We have sampled particularly motivated patients, all of whom were active in treatment. This study group is biasedtoward those who embrace biomedical approaches and does not address the alternative treatment behavior of those who do not. Further research with less motivated patients who are irregular users of clinical services might give us different insights into the prevalence and role of these treatments. Still, our findings raise some important challenges to conventional wisdom in the medical literature regarding the role of traditional health beliefs among Mexican American patients.
Conclusions
In focusing on the alternative treatment beliefs and practices of a group of low-income, low-educational level Mexican Americans, this study challenges some common assumptions about the role of traditional attitudes and health beliefs in their care of type 2 diabetes. Further studies involving a community-based randomized sample including persons not already in clinical care would be necessary to determine if our findings can be generalized to a broader population. Still, at least among those we interviewed, alternative therapies did not present important barriers to medical management of the illness. These findings indicate that patients’ references to alternative treatment or God’s intervention should not instantly label them of fatalistic or noncompliant. Instead, careful consideration of how individuals actually use and evaluate alternative therapies is indicated, to help us better understand how important those treatments might be to these patients and how their use actually affects implementation of prescribed regimens.
Acknowledgments
This research was supported by grants from the South texas Research Center, University of Texas Health Science Center as San Antonio (UTHSCSA) and from the Agency for Health Care Policy and Research, Grant #1-UO1-HSO7397 to the Mexican American Medical Treatment Effectiveness Research Center at UTHSCSA. Interviews were conducted by DeAnn Pendry, Miguel Valenzuela, Armando Cortez, and Linda Hunt. Miguel Valenzuela, Armando Cortez, and Ricardo Montez helped with data analysis. We wish to thank Dr Laura Lein of the Department of Anthropology, University of Texas, Austin, and D. Jacqueline Pugh of the Department of Medicine. University of Texas Health Science Center at San Antonio, for their involvement in our research project. We also wish to thank Robert Wood for his help with statistical analysis. The Institutional Review Board of the University of Texas Health Science Center at San Antonio approved our study. Informed consent was obtained from all participants, and measures have been taken to assure their privacy and anonymity.
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METHODS: Following a descriptive qualitative design, a convenience sample of 43 low-income Mexican Americans with type 2 diabetes were interviewed. We analyzed interview transcripts for alternative treatments named, patterns of use, evaluation of those treatments, and the use of biomedical approaches. We crosschecked the results for interrater reliability.
RESULTS: Herbs were mentioned as possible alternative treatments for diabetes by 84% of the patients interviewed. However, most had never or rarely tried herbs and viewed them as supplemental to medical treatments. Most said prayer influences health by reducing stress and bringing healing power to medicines. None used curanderos (traditional healers) for diabetes. Most actively used biomedical treatments and were less actively involved in alternative approaches. Statistical tests of association showed no competition between biomedical and alternative treatments, and alternative treatment activity tended to be significantly lower than biomedical. Most study participants emphasized medical treatment and only used alternative treatments as secondary strategies. Those patients very actively using alternative approaches also tended to be very actively using biomedical methods; they were using all resources they encountered.
CONCLUSIONS: Traditional attitudes and beliefs were not especially important to the patients in this study and presented no barriers to medical care. For these patients, it also cannot be assumed that belief in alternative treatments and God’s intervention indicate fatalism or noncompliance but instead require consideration of individual treatment behaviors.
Alternative medicine has increasingly become the subject of medical research, in part driven by a concern that such treatments, despite their apparent innocuousness, may harm patients by exposing them to unknown dangers or by drawing them away from medical treatments.1-7 As many as 1 in 3 people in the United States report using alternative treatments, most often for chronic illnesses such as diabetes.8 More than 400 herbal remedies for diabetes have been reported worldwide.9-11 Mexican Americans, who have rates of type 2 diabetes at 2 to 3 times that of the general population,12 also show high interest in alternative medicine, with as many as 67% reportedly using folk remedies.13-15
Although many clinicians worry that alternative treatments may present barriers to effective health care for Mexican American patients with diabetes, research does not support this concern. Several previous studies have focused on alternative treatment use by Mexican Americans,13,14,16-21 but these treatments were not shown to be highly prevalent or of great importance to this group. For example, although many studies have examined use of herbal remedies,22-26 the traditional healers called curanderos,13,17,27 and health-related religious beliefs,4,28-32 most merely report the frequency of these beliefs and practices, without explicitly examining how patients use and evaluate such treatments. There has not been careful consideration of the relative importance of these approaches to the health care of individuals or of how their use affects the utilization of biomedical treatments.
Since noncompliance with medical care is of great concern for physicians of patients with type 2 diabetes,33-36 the question of whether there is competition between biomedical and alternative treatments for this group is an important one. However, a great deal of previous research by anthropologists and other social scientists indicates that this may not be a realistic concern. It has been consistently found that in everyday practice people draw on different health systems simultaneously, using various treatments as complimentary rather than competing alternatives.8,14,37-50 Thus, to understand the role that alternative treatments may play in managing diabetes, it is necessary to not only explore whether those therapies are known and used, but also how their use is integrated with use of biomedical approaches.
We report on a descriptive study of a group of Mexican American patients with type 2 diabetes. We examined how they say they use and evaluate alternative treatments and how they integrate them with conventional medical care.
Methods
Patient Selection
In 1994 and 1995 we discussed alternative treatments for diabetes with a convenience sample of 43 self-identified Mexican American patients. These patients were visiting at 2 public clinics serving low-income patients in San Antonio and Laredo, Texas, for type 2 diabetes. We included patients who had type 2 diabetes for at least 6 months before the interview, had no major impairment because of diabetes, and gave informed consent to be interviewed in their homes. Fifteen patients were recruited while waiting to see internal medicine physicians at the San Antonio clinic. The rest were participating in patient education trials as part of a larger project being conducted by the Texas Diabetes Institute. Nineteen of these were part of a diabetes patient education trial at the San Antonio clinic, and 9 were part of an evaluation of a provider education trial at the Laredo clinic.
Data Collection
We conducted in-depth open-ended interviews following an interview guide of standardized questions. Patients were encouraged to answer in their own words with as much detail as they wished. To facilitate cross-case comparisons, every critical question was asked of all participants. The interviews were conducted in patients’ homes in the language of their preference, lasted approximately 2 hours each, and were tape-recorded and transcribed. The first author (LMH) performed translations from the original Spanish.
The interviews addressed the patients’ personal experiences with diabetes, self-care behaviors, and individual perceptions regarding their health status. Questions about their use of alternative treatments included: Have you ever used or heard of any other kinds of treatments for diabetes? Any home remedies or things like herbs or curanderos? Have you tried them? Do you think they help? Do you think that religion or your spiritual life can affect your health? Do you ever pray about your health or your diabetes? Do you think it helps?
Data Analysis
We indexed all field notes and transcripts by topic and established a filing and retrieval system. We then created a database with variables grounded in open-ended responses to relevant questions. We analyzed this data using SPSS software.51 We also established a method for displaying interview data, building initial matrices of blocks of text (quotations and summations) for each patient that included comments about treatment behaviors and evaluations of their effects. Next, we identified trends and patterns among cases, which we summarized into higher level matrices with the participants grouped by types and patterns of treatment.
We crosschecked all phases of analysis in conference sessions during which the research team reached consensus about applying coding categories and addressed any anomalies or discrepancies. Interrater reliability was established through a second researcher recoding 50% of the case material, validating consistency in coding and classification procedures.
Results
Patients ranged in age from 29 to 69 years with a mean age of 53.9 years. Like most patients in the public clinics from which they were recruited, they were mostly of low-income and low-educational levels, with nearly two thirds unemployed, a mean annual household income of approximately $12,500, and an average of 8.1 years of schooling. Approximately half of the sample chose to be interviewed in Spanish. Approximately half were men, half had diabetes for 6 years or longer, and half had good blood glucose control at the time of the interview. Classification of a participant’s level of glucose control was based on review of medical records from the past year. For glycosylated hemoglobin (Hb A1C), a level of 7.5% or lower was considered good, 7.6% to 10.0% was fair; and higher than 10.0% was poor. If an Hb A1C result was not available, the fasting glucose level was used, with lower than 180 mg/dL considered good, 180 mg/dL to 250 mg/dL fair, and higher than 250 mg/dL poor (Table 1).
Herbal Treatments
When asked if they knew of any treatments for diabetes besides diet, exercise, and medications, 84% of the participants (36/43) said they had heard ofusing herbs to treat the disease (Table 2). The herbs mentioned most often were nopal (prickly pear cactus), 39%; aloe vera, 31%; and nispero (loquat or chinese plum), 17%. However, more than a third of those who mentioned herbs named no specific herb but merely said they had heard herbs could be used (Table 3).
The nopal or prickly pear cactus (opuntia) is a very common plant in South Texas and is a common food item in the region. Its leaves are lightly cooked and mixed with eggs or eaten as a vegetable side dish. Some people in our study reported having increased these dietary uses of nopal as an adjunct to their treatment for diabetes. Others described making a licuado (a drink mixed in an electric blender) out of raw nopal leaves and water; some also added raw aloe vera to this mixture. Most people who described this preparation said they felt it had a positive effect on lowering blood sugar, but some said it had a bitter taste and did not continue to take it after trying it once or twice.
Nispero or loquat (eriobotrya japonica) is also a common plant of the region. It is a large shrub with long leathery leaves that produces clusters of sweet yellow fruit in the spring. Its leaves are brewed into a strong tea that some patients said they drank up to 3 times a day and found helped lower their blood sugar.
Frequency of Herb Use
Very few of our subjects reported using herbs with any regularity (Table 2). Nearly two thirds who named herbs said they had never tried them or had only tried them once or twice, while less than a third said they had regularly used them in the past. Only 9% said they currently use herbs regularly.
Not surprisingly, several of those reporting using herbs regularly felt the herbs helped control their blood sugar. One patient explained his belief that herbs can help in these terms: “What sustains our bodies is what we extract from the earth. So, I mean, what’s wrong with medicinal herbs if they’re doing good?”
The majority of patients, however, were more skeptical about the value of using herbs:
“I’ve heard of them, but I don’t really care too much about them. There’re a lot of people that say herbs can help with the diabetes, but I don’t like to try them. I might be allergic to them or something, or I might get worse off than I am. I’m not gonna take a chance and take something like that.”
“I’ve heard of some [herbs], but I never used any of them. My mother tried them, but I don’t know. I just don’t believe in all that. It’s like remedies for older people.”
“People tell me about [teas], but I haven’t tried any yet. I just take my medicine. If they can’t cure you with medicine, you know, the earth ain’t gonna help you. I don’t want to mix up anything with my medicine.”
Even when people have tried herbs for their diabetes, it cannot be assumed that they believe in their efficacy. Nearly half of those who had tried herbs said they did not help with diabetes or may even have been harmful. In contrast, less than a third felt herbs had a noteworthy positive effect on their illness (Table 2).
Prayer and Curanderos
When asked if they thought God or prayer helped their diabetes, 77% (17/22) said yes (Table 2). It is important to consider the specific ways they believed prayer helps. Most did not think prayer could have a direct impact on their diabetes but instead thought it helped indirectly by reducing their stress and anxiety. A typical comment was: “I ask God to help me with my diabetes. I pray for Him to give me the strength to go on. It makes me feel more tranquil, calmer.”
Several patients (27%, 6/22) said God had a direct influence on their disease management, but this did not excuse them from vigorously pursuing medically recommended treatments. Contrary to the common assumption in the medical literature, we found no patient who thought prayer or God’s help could replace medical treatment. Instead, these patients saw medical treatment as the vehicle through which God would heal them. As one patient explained:
“You have to ask God’s help, you have to pray. God gives the means. He gives us doctors and the medicine, so that they can help us. But, we can’t leave everything to Him. We have to take hold of the means. See, it’s the medicine, but first of all it’s God, and then the medicines. Have faith in what the doctor prescribes.”
Similarly, we found no evidence that these patients turned to traditional healers, such as curanderos, for their diabetes. We did not find a single case of a patient having consulted a curandero for diabetes management. The use of curanderos for any condition among those we interviewed was very rare: Only 3 had ever used a curandero, and all had done so only once and only for diseases other than diabetes (Table 2). Our participants were unanimously skeptical about curanderos:
“I’d rather take the medicine from the doctor than go to the curandero. I don’t believe in them. I think the doctor is best.”
“You have to believe in them (curanderos) for it to work, and I really don’t have trust in them.”
“I wouldn’t have any faith in those guys to tell you the truth. I just don’t think they work. ‘Curandero!’” (Laughs)
Interaction Between Alternative and Biomedical Treatments
We have seen no evidence of any conflict or competition between alternative and conventional treatments among these patients. On the contrary, their comments indicate they may give priority to biomedical regimens over alternative ones. To test this observation, we compared each patient’s level of involvement with biomedical and alternative treatments. On the basis of the individual’s self-reports of treatment behaviors, we classified their level of activity in each type of treatment as high, medium, or low. A scoring method was devised that produced composite scores, reflecting level of activity in each of 3 dimensions of each treatment type. Two researchers independently classified all cases; any discrepancies in classification between them were resolved in meetings of the entire research team.
We scored the level of biomedical activity as follows: Three points were given for taking medications as prescribed, for following a prescribed diet, and for exercising regularly. Two points were given for taking medication but not precisely as prescribed, for following a diet irregularly, and for exercising intermittently. One point was given for having stopped taking medication, for not instituting any dietary changes, and for not exercising.
We scored the level of alternative treatment activity as follows: Three points were given for identifying 2 or more alternative treatments, for currently using an alternative treatment, and for positively evaluating the effect of an alternative treatment on diabetes. Two points were given for listing at least one alternative treatment, for reporting either past or future but not current use of such treatments, and for neutrally evaluating the effectiveness of alternative treatments. One point was given for listing no specific alternative treatments, for not having tried any and not planning to do so, and for negatively evaluating the impact of alternative therapies.
Activity scores for each type of treatment ranged from 3 to 9. Overall activity level was classified as follows: 3 to 4.5 was low, 4.6 to 7.5 was medium, and 7.6 to 9 was high.
The scores for level of activity in biomedical and alternative treatments are summarized in Table 4. Very few patients were inactive in pursuing biomedical treatment, while nearly a third were very actively pursuing it. Although the majority were doing so imperfectly, their interest and intention to follow biomedical regimens was clear. In contrast, the level of involvement with alternative treatments was notably less pronounced. Nearly half were classified as having low activity in alternative treatments, and the rest were divided between high and medium activity levels.
If alternative and biomedical treatment strategies were in competition for these patients, one would expect to see a strong negative correlation between these variables. However, this was not the case (Figure). In fact, the correlation coefficient of r=.155 shows a small positive correlation. That is, people that are active in alternative treatments are somewhat more likely to also be active in biomedical treatment. Furthermore, the paired Student t test shows that, on average, individuals have .338 lower alternative activity scores than biomedical scores and that this is a statistically significant difference with a 2-tailed P value of .017.
Thus, rather than using alternative treatments instead of biomedical treatments, we see the opposite: Our participants were more likely to choose biomedical treatments over alternative methods. For those individuals who were highly engaged in alternative treatments, there was a tendency to also be quite active in biomedical treatments. It seems that patients who are not very interested in biomedical treatments for their diabetes are not very interested in any kind of care. Those who are very interested in alternative treatments seem to be involved in a process of actively seeking solutions to their diabetes, drawing on whatever resources they encounter. The following quotes illustrate this attitude:
“I’ve always gone with what the doctors give me. And now I just want to get off insulin. I’m tired of it. And I’m gonna try as much as I can, whatever they tell me.”
“Herbs are good, but they have to be under medical assistance with an MD, so he can prescribe the medication you need to help you along.”
Discussion
Our study is unique because we not only documented the variety of alternative treatments a group of Mexican American patients were aware of for type 2 diabetes, but also explored how they thought about and used these treatments. We found that although most of these patients could list a variety of herbal treatments for the disease, few reported regularly using them, and few said they found them very effective. Many who did use herbal treatments said they did so only occasionally, and none said they had replaced medical regimens with alternative treatments. None had used curanderos for their diabetes, and although many prayed about their illness, this was done in conjunction with medical treatment, not in its place.
Although the understanding of and compliance with conventional diabetes regimens of many of these patients may be less than optimal,52-54 we found no reason to attribute these limitations to their use of alternative treatments and their religious beliefs and practices. Such approaches are clearly viewed by these patients as supplemental to biomedicine and are not given primary emphasis. Most expressed the attitude that alternative therapies may not help much but probably will not hurt, as long as they are used in conjunction with what medical providers recommend.
It should also be noted that the natural evolution of type 2 diabetes is such that it may progress and remain uncontrolled despite a patient’s best efforts to follow medical advice.55 In this context, our findings suggest that many patients who try alternative therapies may be highly motivated to control their diabetes and engaged in an earnest effort to try all methods available to them. The patients we interviewed were not passively relying solely on alternative treatments but instead pursued several treatment strategies simultaneously.
Furthermore, there is some evidence of the clinical efficacy of the 2 herbs most commonly mentioned by these patients. In laboratory studies, both nopal and nispero have been found to have notable hypoglycemic effects. Studies of both patients with diabetes and of laboratory animals with induced hyperglycemia have reported that these substances decrease serum glucose levels from 17% to 46%.56-62 Although this research area is not well developed, it is possible that these herbs do in fact help reduce glucose levels.
We also found that the role of religion in the management of these patients’ diabetes was not in opposition to their medical treatment but very much in its support. Patients who use prayer and religion to help with illness management are often portrayed in the medical literature as fatalistic, abdicating responsibility for their health care to a higher power, and failing to take care of themselves. Although many of our participants said God is important in controlling their diabetes, they felt God works through the clinician and medications, not in place of them.
Limitations
Our study was designed with the goal of developing a thorough understanding of the treatment concepts and practices of the participants. It was not designed to produce generalizable findings. Our findings should not be taken to refer to a broader population but should be viewed as a window on how a group of individuals think about and use these treatment systems. We have chosen to note percentages in reporting our findings to show the distribution of a concept or behavior within our study group. This should not be taken to imply an expected prevalence in a larger population.
It also must be emphasized that these are tentative findings. They are based on a relatively small convenience sample drawn from patients already receiving clinical care or participating in education intervention trials. We have sampled particularly motivated patients, all of whom were active in treatment. This study group is biasedtoward those who embrace biomedical approaches and does not address the alternative treatment behavior of those who do not. Further research with less motivated patients who are irregular users of clinical services might give us different insights into the prevalence and role of these treatments. Still, our findings raise some important challenges to conventional wisdom in the medical literature regarding the role of traditional health beliefs among Mexican American patients.
Conclusions
In focusing on the alternative treatment beliefs and practices of a group of low-income, low-educational level Mexican Americans, this study challenges some common assumptions about the role of traditional attitudes and health beliefs in their care of type 2 diabetes. Further studies involving a community-based randomized sample including persons not already in clinical care would be necessary to determine if our findings can be generalized to a broader population. Still, at least among those we interviewed, alternative therapies did not present important barriers to medical management of the illness. These findings indicate that patients’ references to alternative treatment or God’s intervention should not instantly label them of fatalistic or noncompliant. Instead, careful consideration of how individuals actually use and evaluate alternative therapies is indicated, to help us better understand how important those treatments might be to these patients and how their use actually affects implementation of prescribed regimens.
Acknowledgments
This research was supported by grants from the South texas Research Center, University of Texas Health Science Center as San Antonio (UTHSCSA) and from the Agency for Health Care Policy and Research, Grant #1-UO1-HSO7397 to the Mexican American Medical Treatment Effectiveness Research Center at UTHSCSA. Interviews were conducted by DeAnn Pendry, Miguel Valenzuela, Armando Cortez, and Linda Hunt. Miguel Valenzuela, Armando Cortez, and Ricardo Montez helped with data analysis. We wish to thank Dr Laura Lein of the Department of Anthropology, University of Texas, Austin, and D. Jacqueline Pugh of the Department of Medicine. University of Texas Health Science Center at San Antonio, for their involvement in our research project. We also wish to thank Robert Wood for his help with statistical analysis. The Institutional Review Board of the University of Texas Health Science Center at San Antonio approved our study. Informed consent was obtained from all participants, and measures have been taken to assure their privacy and anonymity.
METHODS: Following a descriptive qualitative design, a convenience sample of 43 low-income Mexican Americans with type 2 diabetes were interviewed. We analyzed interview transcripts for alternative treatments named, patterns of use, evaluation of those treatments, and the use of biomedical approaches. We crosschecked the results for interrater reliability.
RESULTS: Herbs were mentioned as possible alternative treatments for diabetes by 84% of the patients interviewed. However, most had never or rarely tried herbs and viewed them as supplemental to medical treatments. Most said prayer influences health by reducing stress and bringing healing power to medicines. None used curanderos (traditional healers) for diabetes. Most actively used biomedical treatments and were less actively involved in alternative approaches. Statistical tests of association showed no competition between biomedical and alternative treatments, and alternative treatment activity tended to be significantly lower than biomedical. Most study participants emphasized medical treatment and only used alternative treatments as secondary strategies. Those patients very actively using alternative approaches also tended to be very actively using biomedical methods; they were using all resources they encountered.
CONCLUSIONS: Traditional attitudes and beliefs were not especially important to the patients in this study and presented no barriers to medical care. For these patients, it also cannot be assumed that belief in alternative treatments and God’s intervention indicate fatalism or noncompliance but instead require consideration of individual treatment behaviors.
Alternative medicine has increasingly become the subject of medical research, in part driven by a concern that such treatments, despite their apparent innocuousness, may harm patients by exposing them to unknown dangers or by drawing them away from medical treatments.1-7 As many as 1 in 3 people in the United States report using alternative treatments, most often for chronic illnesses such as diabetes.8 More than 400 herbal remedies for diabetes have been reported worldwide.9-11 Mexican Americans, who have rates of type 2 diabetes at 2 to 3 times that of the general population,12 also show high interest in alternative medicine, with as many as 67% reportedly using folk remedies.13-15
Although many clinicians worry that alternative treatments may present barriers to effective health care for Mexican American patients with diabetes, research does not support this concern. Several previous studies have focused on alternative treatment use by Mexican Americans,13,14,16-21 but these treatments were not shown to be highly prevalent or of great importance to this group. For example, although many studies have examined use of herbal remedies,22-26 the traditional healers called curanderos,13,17,27 and health-related religious beliefs,4,28-32 most merely report the frequency of these beliefs and practices, without explicitly examining how patients use and evaluate such treatments. There has not been careful consideration of the relative importance of these approaches to the health care of individuals or of how their use affects the utilization of biomedical treatments.
Since noncompliance with medical care is of great concern for physicians of patients with type 2 diabetes,33-36 the question of whether there is competition between biomedical and alternative treatments for this group is an important one. However, a great deal of previous research by anthropologists and other social scientists indicates that this may not be a realistic concern. It has been consistently found that in everyday practice people draw on different health systems simultaneously, using various treatments as complimentary rather than competing alternatives.8,14,37-50 Thus, to understand the role that alternative treatments may play in managing diabetes, it is necessary to not only explore whether those therapies are known and used, but also how their use is integrated with use of biomedical approaches.
We report on a descriptive study of a group of Mexican American patients with type 2 diabetes. We examined how they say they use and evaluate alternative treatments and how they integrate them with conventional medical care.
Methods
Patient Selection
In 1994 and 1995 we discussed alternative treatments for diabetes with a convenience sample of 43 self-identified Mexican American patients. These patients were visiting at 2 public clinics serving low-income patients in San Antonio and Laredo, Texas, for type 2 diabetes. We included patients who had type 2 diabetes for at least 6 months before the interview, had no major impairment because of diabetes, and gave informed consent to be interviewed in their homes. Fifteen patients were recruited while waiting to see internal medicine physicians at the San Antonio clinic. The rest were participating in patient education trials as part of a larger project being conducted by the Texas Diabetes Institute. Nineteen of these were part of a diabetes patient education trial at the San Antonio clinic, and 9 were part of an evaluation of a provider education trial at the Laredo clinic.
Data Collection
We conducted in-depth open-ended interviews following an interview guide of standardized questions. Patients were encouraged to answer in their own words with as much detail as they wished. To facilitate cross-case comparisons, every critical question was asked of all participants. The interviews were conducted in patients’ homes in the language of their preference, lasted approximately 2 hours each, and were tape-recorded and transcribed. The first author (LMH) performed translations from the original Spanish.
The interviews addressed the patients’ personal experiences with diabetes, self-care behaviors, and individual perceptions regarding their health status. Questions about their use of alternative treatments included: Have you ever used or heard of any other kinds of treatments for diabetes? Any home remedies or things like herbs or curanderos? Have you tried them? Do you think they help? Do you think that religion or your spiritual life can affect your health? Do you ever pray about your health or your diabetes? Do you think it helps?
Data Analysis
We indexed all field notes and transcripts by topic and established a filing and retrieval system. We then created a database with variables grounded in open-ended responses to relevant questions. We analyzed this data using SPSS software.51 We also established a method for displaying interview data, building initial matrices of blocks of text (quotations and summations) for each patient that included comments about treatment behaviors and evaluations of their effects. Next, we identified trends and patterns among cases, which we summarized into higher level matrices with the participants grouped by types and patterns of treatment.
We crosschecked all phases of analysis in conference sessions during which the research team reached consensus about applying coding categories and addressed any anomalies or discrepancies. Interrater reliability was established through a second researcher recoding 50% of the case material, validating consistency in coding and classification procedures.
Results
Patients ranged in age from 29 to 69 years with a mean age of 53.9 years. Like most patients in the public clinics from which they were recruited, they were mostly of low-income and low-educational levels, with nearly two thirds unemployed, a mean annual household income of approximately $12,500, and an average of 8.1 years of schooling. Approximately half of the sample chose to be interviewed in Spanish. Approximately half were men, half had diabetes for 6 years or longer, and half had good blood glucose control at the time of the interview. Classification of a participant’s level of glucose control was based on review of medical records from the past year. For glycosylated hemoglobin (Hb A1C), a level of 7.5% or lower was considered good, 7.6% to 10.0% was fair; and higher than 10.0% was poor. If an Hb A1C result was not available, the fasting glucose level was used, with lower than 180 mg/dL considered good, 180 mg/dL to 250 mg/dL fair, and higher than 250 mg/dL poor (Table 1).
Herbal Treatments
When asked if they knew of any treatments for diabetes besides diet, exercise, and medications, 84% of the participants (36/43) said they had heard ofusing herbs to treat the disease (Table 2). The herbs mentioned most often were nopal (prickly pear cactus), 39%; aloe vera, 31%; and nispero (loquat or chinese plum), 17%. However, more than a third of those who mentioned herbs named no specific herb but merely said they had heard herbs could be used (Table 3).
The nopal or prickly pear cactus (opuntia) is a very common plant in South Texas and is a common food item in the region. Its leaves are lightly cooked and mixed with eggs or eaten as a vegetable side dish. Some people in our study reported having increased these dietary uses of nopal as an adjunct to their treatment for diabetes. Others described making a licuado (a drink mixed in an electric blender) out of raw nopal leaves and water; some also added raw aloe vera to this mixture. Most people who described this preparation said they felt it had a positive effect on lowering blood sugar, but some said it had a bitter taste and did not continue to take it after trying it once or twice.
Nispero or loquat (eriobotrya japonica) is also a common plant of the region. It is a large shrub with long leathery leaves that produces clusters of sweet yellow fruit in the spring. Its leaves are brewed into a strong tea that some patients said they drank up to 3 times a day and found helped lower their blood sugar.
Frequency of Herb Use
Very few of our subjects reported using herbs with any regularity (Table 2). Nearly two thirds who named herbs said they had never tried them or had only tried them once or twice, while less than a third said they had regularly used them in the past. Only 9% said they currently use herbs regularly.
Not surprisingly, several of those reporting using herbs regularly felt the herbs helped control their blood sugar. One patient explained his belief that herbs can help in these terms: “What sustains our bodies is what we extract from the earth. So, I mean, what’s wrong with medicinal herbs if they’re doing good?”
The majority of patients, however, were more skeptical about the value of using herbs:
“I’ve heard of them, but I don’t really care too much about them. There’re a lot of people that say herbs can help with the diabetes, but I don’t like to try them. I might be allergic to them or something, or I might get worse off than I am. I’m not gonna take a chance and take something like that.”
“I’ve heard of some [herbs], but I never used any of them. My mother tried them, but I don’t know. I just don’t believe in all that. It’s like remedies for older people.”
“People tell me about [teas], but I haven’t tried any yet. I just take my medicine. If they can’t cure you with medicine, you know, the earth ain’t gonna help you. I don’t want to mix up anything with my medicine.”
Even when people have tried herbs for their diabetes, it cannot be assumed that they believe in their efficacy. Nearly half of those who had tried herbs said they did not help with diabetes or may even have been harmful. In contrast, less than a third felt herbs had a noteworthy positive effect on their illness (Table 2).
Prayer and Curanderos
When asked if they thought God or prayer helped their diabetes, 77% (17/22) said yes (Table 2). It is important to consider the specific ways they believed prayer helps. Most did not think prayer could have a direct impact on their diabetes but instead thought it helped indirectly by reducing their stress and anxiety. A typical comment was: “I ask God to help me with my diabetes. I pray for Him to give me the strength to go on. It makes me feel more tranquil, calmer.”
Several patients (27%, 6/22) said God had a direct influence on their disease management, but this did not excuse them from vigorously pursuing medically recommended treatments. Contrary to the common assumption in the medical literature, we found no patient who thought prayer or God’s help could replace medical treatment. Instead, these patients saw medical treatment as the vehicle through which God would heal them. As one patient explained:
“You have to ask God’s help, you have to pray. God gives the means. He gives us doctors and the medicine, so that they can help us. But, we can’t leave everything to Him. We have to take hold of the means. See, it’s the medicine, but first of all it’s God, and then the medicines. Have faith in what the doctor prescribes.”
Similarly, we found no evidence that these patients turned to traditional healers, such as curanderos, for their diabetes. We did not find a single case of a patient having consulted a curandero for diabetes management. The use of curanderos for any condition among those we interviewed was very rare: Only 3 had ever used a curandero, and all had done so only once and only for diseases other than diabetes (Table 2). Our participants were unanimously skeptical about curanderos:
“I’d rather take the medicine from the doctor than go to the curandero. I don’t believe in them. I think the doctor is best.”
“You have to believe in them (curanderos) for it to work, and I really don’t have trust in them.”
“I wouldn’t have any faith in those guys to tell you the truth. I just don’t think they work. ‘Curandero!’” (Laughs)
Interaction Between Alternative and Biomedical Treatments
We have seen no evidence of any conflict or competition between alternative and conventional treatments among these patients. On the contrary, their comments indicate they may give priority to biomedical regimens over alternative ones. To test this observation, we compared each patient’s level of involvement with biomedical and alternative treatments. On the basis of the individual’s self-reports of treatment behaviors, we classified their level of activity in each type of treatment as high, medium, or low. A scoring method was devised that produced composite scores, reflecting level of activity in each of 3 dimensions of each treatment type. Two researchers independently classified all cases; any discrepancies in classification between them were resolved in meetings of the entire research team.
We scored the level of biomedical activity as follows: Three points were given for taking medications as prescribed, for following a prescribed diet, and for exercising regularly. Two points were given for taking medication but not precisely as prescribed, for following a diet irregularly, and for exercising intermittently. One point was given for having stopped taking medication, for not instituting any dietary changes, and for not exercising.
We scored the level of alternative treatment activity as follows: Three points were given for identifying 2 or more alternative treatments, for currently using an alternative treatment, and for positively evaluating the effect of an alternative treatment on diabetes. Two points were given for listing at least one alternative treatment, for reporting either past or future but not current use of such treatments, and for neutrally evaluating the effectiveness of alternative treatments. One point was given for listing no specific alternative treatments, for not having tried any and not planning to do so, and for negatively evaluating the impact of alternative therapies.
Activity scores for each type of treatment ranged from 3 to 9. Overall activity level was classified as follows: 3 to 4.5 was low, 4.6 to 7.5 was medium, and 7.6 to 9 was high.
The scores for level of activity in biomedical and alternative treatments are summarized in Table 4. Very few patients were inactive in pursuing biomedical treatment, while nearly a third were very actively pursuing it. Although the majority were doing so imperfectly, their interest and intention to follow biomedical regimens was clear. In contrast, the level of involvement with alternative treatments was notably less pronounced. Nearly half were classified as having low activity in alternative treatments, and the rest were divided between high and medium activity levels.
If alternative and biomedical treatment strategies were in competition for these patients, one would expect to see a strong negative correlation between these variables. However, this was not the case (Figure). In fact, the correlation coefficient of r=.155 shows a small positive correlation. That is, people that are active in alternative treatments are somewhat more likely to also be active in biomedical treatment. Furthermore, the paired Student t test shows that, on average, individuals have .338 lower alternative activity scores than biomedical scores and that this is a statistically significant difference with a 2-tailed P value of .017.
Thus, rather than using alternative treatments instead of biomedical treatments, we see the opposite: Our participants were more likely to choose biomedical treatments over alternative methods. For those individuals who were highly engaged in alternative treatments, there was a tendency to also be quite active in biomedical treatments. It seems that patients who are not very interested in biomedical treatments for their diabetes are not very interested in any kind of care. Those who are very interested in alternative treatments seem to be involved in a process of actively seeking solutions to their diabetes, drawing on whatever resources they encounter. The following quotes illustrate this attitude:
“I’ve always gone with what the doctors give me. And now I just want to get off insulin. I’m tired of it. And I’m gonna try as much as I can, whatever they tell me.”
“Herbs are good, but they have to be under medical assistance with an MD, so he can prescribe the medication you need to help you along.”
Discussion
Our study is unique because we not only documented the variety of alternative treatments a group of Mexican American patients were aware of for type 2 diabetes, but also explored how they thought about and used these treatments. We found that although most of these patients could list a variety of herbal treatments for the disease, few reported regularly using them, and few said they found them very effective. Many who did use herbal treatments said they did so only occasionally, and none said they had replaced medical regimens with alternative treatments. None had used curanderos for their diabetes, and although many prayed about their illness, this was done in conjunction with medical treatment, not in its place.
Although the understanding of and compliance with conventional diabetes regimens of many of these patients may be less than optimal,52-54 we found no reason to attribute these limitations to their use of alternative treatments and their religious beliefs and practices. Such approaches are clearly viewed by these patients as supplemental to biomedicine and are not given primary emphasis. Most expressed the attitude that alternative therapies may not help much but probably will not hurt, as long as they are used in conjunction with what medical providers recommend.
It should also be noted that the natural evolution of type 2 diabetes is such that it may progress and remain uncontrolled despite a patient’s best efforts to follow medical advice.55 In this context, our findings suggest that many patients who try alternative therapies may be highly motivated to control their diabetes and engaged in an earnest effort to try all methods available to them. The patients we interviewed were not passively relying solely on alternative treatments but instead pursued several treatment strategies simultaneously.
Furthermore, there is some evidence of the clinical efficacy of the 2 herbs most commonly mentioned by these patients. In laboratory studies, both nopal and nispero have been found to have notable hypoglycemic effects. Studies of both patients with diabetes and of laboratory animals with induced hyperglycemia have reported that these substances decrease serum glucose levels from 17% to 46%.56-62 Although this research area is not well developed, it is possible that these herbs do in fact help reduce glucose levels.
We also found that the role of religion in the management of these patients’ diabetes was not in opposition to their medical treatment but very much in its support. Patients who use prayer and religion to help with illness management are often portrayed in the medical literature as fatalistic, abdicating responsibility for their health care to a higher power, and failing to take care of themselves. Although many of our participants said God is important in controlling their diabetes, they felt God works through the clinician and medications, not in place of them.
Limitations
Our study was designed with the goal of developing a thorough understanding of the treatment concepts and practices of the participants. It was not designed to produce generalizable findings. Our findings should not be taken to refer to a broader population but should be viewed as a window on how a group of individuals think about and use these treatment systems. We have chosen to note percentages in reporting our findings to show the distribution of a concept or behavior within our study group. This should not be taken to imply an expected prevalence in a larger population.
It also must be emphasized that these are tentative findings. They are based on a relatively small convenience sample drawn from patients already receiving clinical care or participating in education intervention trials. We have sampled particularly motivated patients, all of whom were active in treatment. This study group is biasedtoward those who embrace biomedical approaches and does not address the alternative treatment behavior of those who do not. Further research with less motivated patients who are irregular users of clinical services might give us different insights into the prevalence and role of these treatments. Still, our findings raise some important challenges to conventional wisdom in the medical literature regarding the role of traditional health beliefs among Mexican American patients.
Conclusions
In focusing on the alternative treatment beliefs and practices of a group of low-income, low-educational level Mexican Americans, this study challenges some common assumptions about the role of traditional attitudes and health beliefs in their care of type 2 diabetes. Further studies involving a community-based randomized sample including persons not already in clinical care would be necessary to determine if our findings can be generalized to a broader population. Still, at least among those we interviewed, alternative therapies did not present important barriers to medical management of the illness. These findings indicate that patients’ references to alternative treatment or God’s intervention should not instantly label them of fatalistic or noncompliant. Instead, careful consideration of how individuals actually use and evaluate alternative therapies is indicated, to help us better understand how important those treatments might be to these patients and how their use actually affects implementation of prescribed regimens.
Acknowledgments
This research was supported by grants from the South texas Research Center, University of Texas Health Science Center as San Antonio (UTHSCSA) and from the Agency for Health Care Policy and Research, Grant #1-UO1-HSO7397 to the Mexican American Medical Treatment Effectiveness Research Center at UTHSCSA. Interviews were conducted by DeAnn Pendry, Miguel Valenzuela, Armando Cortez, and Linda Hunt. Miguel Valenzuela, Armando Cortez, and Ricardo Montez helped with data analysis. We wish to thank Dr Laura Lein of the Department of Anthropology, University of Texas, Austin, and D. Jacqueline Pugh of the Department of Medicine. University of Texas Health Science Center at San Antonio, for their involvement in our research project. We also wish to thank Robert Wood for his help with statistical analysis. The Institutional Review Board of the University of Texas Health Science Center at San Antonio approved our study. Informed consent was obtained from all participants, and measures have been taken to assure their privacy and anonymity.
1. Delbanco TL. Bitter herbs: mainstream, magic, and menace, Ann Intern Med 1994;121:803-4.
2. Cottrell K. Herbal products begin to attract the attention of brand-name drug companies. Can Med Assoc J 1996;155:216-9.
3. Goldbeck-Wood S, Dorozynski A, Lie LG, et al. Complementary medicine is booming worldwide. BMJ 1996;313:131-3.
4. Gill GV, Redmond S, Garratt F, Paisey R. Diabetes and alternative medicine: cause for concern. Diabetic Med 1994;11:210-3.
5. Ewins DL, Bakker K, Young MJ, Boulton AJ. Alternative medicine: potential dangers for the diabetic foot. Diabetic Med 1993;10:980-2.
6. Kirsti AM. Defining and assessing alternative medicine practices. JAMA 1996;276:195-6.
7. Foote J, Cohen B. Medicinal herb use and the renal patient. J Renal Nutrition 1998;8:40-2.
8. Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States: prevalence, costs, and patterns of use. N Engl J Med 1993;328:246-52.
9. Bailey CJ, Day C. Traditional plant medicines as treatments for diabetes. Diabetes Care 1989;12:553-64.
10. Krastins M, Ristinen E, Cimino JA, Mamtani R. Use of alternative therapies by a low income population. Acupunct Electrother Res 1998;23:135-42.
11. Miller M, Boyer MJ, Butow PN, Gattellari M, Dunn SM, Childs A. The use of unproven methods of treatment by cancer patients: frequency, expectations, and cost. Supportive Care Cancer 1998;6:337-47.
12. Stern MP, Mitchell B. Diabetes in Hispanic Americans. In: National Diabetes Data Group, National Institute of Diabetes and Digestive and Kidney Disease, eds. Diabetes in America. 2nd ed. Bethesda, Md: National Diabetes Information Clearinghouse; 1995;631-59.
13. Marsh WW, Hentges K. Mexican folk remedies and conventional medical care. Am Fam Physician 1988;37:257-62.
14. Chesney AP, Thompson BL, Guevara A, Vela A, Schottstaedt MF. Mexican-American folk medicine: implications for the family physician. J Fam Pract 1980;11:567-74.
15. Hitchcock Noel P, Pugh JA, Larme AC, Marsh G. The use of traditional plant medicines for non-insulin dependent diabetes mellitus in South Texas. Phytotherapy Res 1997;11:512-7.
16. Zaldivar A, Smolowitz J. Perceptions of the importance placed on religion and folk medicine by non-Mexican-American Hispanic adults with diabetes. Diabetes Educator 1994;20:303-6.
17. Andersen R, Lewis SZ, Giachello AL, Aday LA, Chiu G. Access to medical care among the Hispanic population of the south-western United States. J Health Soc Behav 1981;22:78-89.
18. Pousada L. Hispanic-American elders: implications for health-care providers. Clin Geriatric Med 1995;11:39-52.
19. Castro FG, Furth P, Karlow H. The health beliefs of Mexican, Mexican American, and Anglo American Women. Hispanic J Behav Sci 1984;6:365-83.
20. Baer RD, Garcia DA, Leal RM, Plascencia Campos AR, Goslin N. Mexican use of lead in the treatment of empacho: community, clinic, and longitudinal patterns. Soc Sci Med 1998;47:1263-66.
21. Weller SC, Ruebush TR, Klein RE. Predicting treatment-seeking behavior in Guatermala: a Comparison of the health Services research and decision-theoretic approaches. Med Anthropol Q 1997;11:224-45.
22. Sandler AP, Chan LS. Mexican-American folk belief in a pediatric emergency room. Med Care 1978;16:778-84.
23. Keegan L. Use of alternative therapies among Mexican Americans in the Texas Rio Grande Valley. J Holistic Nurs 1996;14:277-94.
24. Zuckerman MJ, Guerra LG, Drossman DA, Foland JA, Gregory GG. Health-care-seeking behaviors related to bowel complaints: Hispanies versus non-Hispanic whites. Dig Dis Sci 1996;41:77-82.
25. Risser AL, Mazur LJ. Use of folk remedies in a Hispanic population. Arch Pediatr Adolesc Med 1995;149:978-81.
26. Mikhail BI. Hispanic mothers’ beliefs and practices regarding selected children’s health problems. West J Nurs Res 1994;16:623-38.
27. Higginbotham JC, Trevino FM, Ray LA. Utilization of curanderos by Mexican Americans: prevalence and predictors findings from HHanes 1982-84. Am J Public Health 1990;80:32-5.
28. Schwab T, Meyer J, Merrell R. Measuring attitudes and health beliefs among Mexican Americans with diabetes. Diabetes Educator 1994;20:221-35.
29. Tamez EG, Vacalis TD. Health beliefs, the significant other and compliance with therapeutic regimens among adult Mexican American diabetics. Health Educ 1989;20:24-31.
30. Womack R. Measuring the attitudes and beliefs of American Indian patients with diabetes. Diabetes Educator 1993;19:205-9.
31. Quatromoni P, Milbauer M, Posner B, Carballeira N, Brunt M, Chipkin S. Use of focus groups to explore nutrition practices and health beliefs of urban Caribbean Latinos with diabetes. Diabetes Care 1994;17:869-73.
32. Hazuda HP, Haffner SM, Stern MP, Eifler CW. Effects of acculturation and socioeconomic status on obesity and diabetes in Mexican Americans. Am J Epidemiol 1988;128:1289-301.
33. Johnson SB. Methodological issues in diabetes research: measuring adherence. Diabetes Care 1992;15:1658-67.
34. Kurtz SM. Adherence to diabetes regimens: empirical status and clinical applications. Diabetes Educator 1990;16:50-9.
35. Rosenstock IM. Understanding and enhancing patient compliance with diabetic regimens. Diabetes Care 1985;8:610-6.
36. Cox DJ, Gonder-Frederick L. Major developments in behavioral diabetes research. J Cons Clin Psych 1992;60:628-38.
37. Applewhite SL. Guranderismo: demystifying the health beliefs and practices of elderly Mexican Americans. Health Soc Work 1995;20:247-53.
38. Hunt LM, Jordan B, Irwin S, Browner CH. Compliance and the patient’s perspective: controlling symptoms in everyday life. Cult Med Psychiatry 1989;13:315-34.
39. Kleinman A. Patients and healers in the context of culture, Berkeley, Calif: University of California Press; 1980.
40. Brodwin P. Political contests and moral claims: religious pluralism and healing in a Haitian village. Boston, Mass: Harvard University; 1991.
41. Cosminsky S. Medical pluralism in Mesoamerica. In: Kendall C, ed. Heritage of conquest: thirty years later. Albuquerque, NM: University of New Mexico Press; 1983;159-73.
42. Cosminsky S, Scrimshaw M. Medical pluralism on a Guatemala plantation. Soc Sci Med 1980;14B:267-78.
43. Finkler K. A comparative study of health seekers: or, why do some people go to the doctor rather than to a spiritualist healer. Med Anthropol 1981;5:383-424.
44. Helman C. “Feed a cold, starve a fever” folk models of infection in an English suburban community, and their relation to medical treatment. Cult Med Psychiatry 1978;2:137.-
45. Higgins C. Integrative aspects of folk and Western medicine among urban poor of Oaxaca. Anthropol Q 1975;48:31-7.
46. Janzen J. The quest for therapy: medical pluralism in Lower Zaire. Berkeley, Calif: University of California Press: 1978.
47. Low S. Culture, politics and medicine in Costa Rica: an anthropological study of medical change. Bedford Hills, NY: Redgrave: 1985.
48. Nichter M. The layperson’s perception of medicine as perspective into the utilization of multiple therapy systems in the Indian context. Soc Sci Med 1980;14B:225-33.
49. Romanucci-Ross L. The hierarchy of resort in curative practices: the Admiralty Islands, Melanesia. J Health Soc Behav 1969;10:201-9.
50. Young J, Garro L. Variations in the choice of treatment in two Mexican communities. Soc Sci Med 1982;16:1453-65.
51. Norusis MJ. SPSS for Windows: base system user’s guide. Release 6.0. Chicago, Ill: SPSS Inc; 1993.
52. Hunt LM, Valenzuela MA, Pugh JA. “Porque me tocó a m1?”: Mexican American diabetes patients’ causal stories and their relationship to treatment behaviors. Soc Sci Med 1998;46:959-69.
53. Hunt LM, Valenzuela MA, Pugh JA. NIDDM patients’ fears and hopes about insulin therapy: the basis of patient reluctance. Diabetes Care 1996-7;20:292-8.
54. Hunt LM, Pugh JA, Valenzuela MA. How patients adapt diabetes self-care recommendations in everyday life. J Fam Pract 1998;46:207-15.
55. American Diabetes Association. Implications of the Diabetes Control and Complications Trial. Diabetes Care 1997;20(suppl):S62-4.
56. Roman-Ramos R, Flores-Saenz JL, Partida-Hernandez G, Lara-Lemus A, Alarcon-Aguilar F. Experimental study of the hypoglycemic effect of some antidiabetic plants. Arch Invest Med 1991;22:87-93.
57. De Tommasi N, De Simone F, Cirino G, Cicala C, Pizza C. Hypoglycemic effects of sesquiterpene glycosides and polyhydroxylated triterpenoids of Eriobotrya japonica. Planta Med 1991;57:414-6.
58. Noreen W, Wadood A, Hidayat HK, Wahid SA. Effect of Eriobotrya japonica on blood glucose levels of normal and alloxan-diabetic rabbits. Planta Med 1988;54:196-9.
59. Trejo-Gonzalez A, Gabriel-Ortiz G, Puebla-Perez AM, et al. A purified extract from prickly pear cactus (Opuntia fuliginosa) controls experimentally induced diabetes in rats. J Ethnopharmacol 1996;55:27-33.
60. Roman-Ramos R, Flores-Saenz JL, Alarcon-Aguilar FJ. Anti-hyperglycemic effect of some edible plants. J Ethnopharmacol 1995;48:25-32.
61. Frati AC, Xilotl Diaz N, Altamirano P, Ariza R, Lopez-Ledesma R. The effect of two sequential doses of Opuntia streptacantha upon glycemia. Arch Invest Med 1991;22:333-6.
62. Ibanez-Camacho R, Meckes-Lozoya M. Effect of a semipurified product obtained from Opuntia streptacantha L. (a cactus) on glycemia and triglyceridemia of rabbit. Arch Invest Med 1983;14:437-43.
1. Delbanco TL. Bitter herbs: mainstream, magic, and menace, Ann Intern Med 1994;121:803-4.
2. Cottrell K. Herbal products begin to attract the attention of brand-name drug companies. Can Med Assoc J 1996;155:216-9.
3. Goldbeck-Wood S, Dorozynski A, Lie LG, et al. Complementary medicine is booming worldwide. BMJ 1996;313:131-3.
4. Gill GV, Redmond S, Garratt F, Paisey R. Diabetes and alternative medicine: cause for concern. Diabetic Med 1994;11:210-3.
5. Ewins DL, Bakker K, Young MJ, Boulton AJ. Alternative medicine: potential dangers for the diabetic foot. Diabetic Med 1993;10:980-2.
6. Kirsti AM. Defining and assessing alternative medicine practices. JAMA 1996;276:195-6.
7. Foote J, Cohen B. Medicinal herb use and the renal patient. J Renal Nutrition 1998;8:40-2.
8. Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States: prevalence, costs, and patterns of use. N Engl J Med 1993;328:246-52.
9. Bailey CJ, Day C. Traditional plant medicines as treatments for diabetes. Diabetes Care 1989;12:553-64.
10. Krastins M, Ristinen E, Cimino JA, Mamtani R. Use of alternative therapies by a low income population. Acupunct Electrother Res 1998;23:135-42.
11. Miller M, Boyer MJ, Butow PN, Gattellari M, Dunn SM, Childs A. The use of unproven methods of treatment by cancer patients: frequency, expectations, and cost. Supportive Care Cancer 1998;6:337-47.
12. Stern MP, Mitchell B. Diabetes in Hispanic Americans. In: National Diabetes Data Group, National Institute of Diabetes and Digestive and Kidney Disease, eds. Diabetes in America. 2nd ed. Bethesda, Md: National Diabetes Information Clearinghouse; 1995;631-59.
13. Marsh WW, Hentges K. Mexican folk remedies and conventional medical care. Am Fam Physician 1988;37:257-62.
14. Chesney AP, Thompson BL, Guevara A, Vela A, Schottstaedt MF. Mexican-American folk medicine: implications for the family physician. J Fam Pract 1980;11:567-74.
15. Hitchcock Noel P, Pugh JA, Larme AC, Marsh G. The use of traditional plant medicines for non-insulin dependent diabetes mellitus in South Texas. Phytotherapy Res 1997;11:512-7.
16. Zaldivar A, Smolowitz J. Perceptions of the importance placed on religion and folk medicine by non-Mexican-American Hispanic adults with diabetes. Diabetes Educator 1994;20:303-6.
17. Andersen R, Lewis SZ, Giachello AL, Aday LA, Chiu G. Access to medical care among the Hispanic population of the south-western United States. J Health Soc Behav 1981;22:78-89.
18. Pousada L. Hispanic-American elders: implications for health-care providers. Clin Geriatric Med 1995;11:39-52.
19. Castro FG, Furth P, Karlow H. The health beliefs of Mexican, Mexican American, and Anglo American Women. Hispanic J Behav Sci 1984;6:365-83.
20. Baer RD, Garcia DA, Leal RM, Plascencia Campos AR, Goslin N. Mexican use of lead in the treatment of empacho: community, clinic, and longitudinal patterns. Soc Sci Med 1998;47:1263-66.
21. Weller SC, Ruebush TR, Klein RE. Predicting treatment-seeking behavior in Guatermala: a Comparison of the health Services research and decision-theoretic approaches. Med Anthropol Q 1997;11:224-45.
22. Sandler AP, Chan LS. Mexican-American folk belief in a pediatric emergency room. Med Care 1978;16:778-84.
23. Keegan L. Use of alternative therapies among Mexican Americans in the Texas Rio Grande Valley. J Holistic Nurs 1996;14:277-94.
24. Zuckerman MJ, Guerra LG, Drossman DA, Foland JA, Gregory GG. Health-care-seeking behaviors related to bowel complaints: Hispanies versus non-Hispanic whites. Dig Dis Sci 1996;41:77-82.
25. Risser AL, Mazur LJ. Use of folk remedies in a Hispanic population. Arch Pediatr Adolesc Med 1995;149:978-81.
26. Mikhail BI. Hispanic mothers’ beliefs and practices regarding selected children’s health problems. West J Nurs Res 1994;16:623-38.
27. Higginbotham JC, Trevino FM, Ray LA. Utilization of curanderos by Mexican Americans: prevalence and predictors findings from HHanes 1982-84. Am J Public Health 1990;80:32-5.
28. Schwab T, Meyer J, Merrell R. Measuring attitudes and health beliefs among Mexican Americans with diabetes. Diabetes Educator 1994;20:221-35.
29. Tamez EG, Vacalis TD. Health beliefs, the significant other and compliance with therapeutic regimens among adult Mexican American diabetics. Health Educ 1989;20:24-31.
30. Womack R. Measuring the attitudes and beliefs of American Indian patients with diabetes. Diabetes Educator 1993;19:205-9.
31. Quatromoni P, Milbauer M, Posner B, Carballeira N, Brunt M, Chipkin S. Use of focus groups to explore nutrition practices and health beliefs of urban Caribbean Latinos with diabetes. Diabetes Care 1994;17:869-73.
32. Hazuda HP, Haffner SM, Stern MP, Eifler CW. Effects of acculturation and socioeconomic status on obesity and diabetes in Mexican Americans. Am J Epidemiol 1988;128:1289-301.
33. Johnson SB. Methodological issues in diabetes research: measuring adherence. Diabetes Care 1992;15:1658-67.
34. Kurtz SM. Adherence to diabetes regimens: empirical status and clinical applications. Diabetes Educator 1990;16:50-9.
35. Rosenstock IM. Understanding and enhancing patient compliance with diabetic regimens. Diabetes Care 1985;8:610-6.
36. Cox DJ, Gonder-Frederick L. Major developments in behavioral diabetes research. J Cons Clin Psych 1992;60:628-38.
37. Applewhite SL. Guranderismo: demystifying the health beliefs and practices of elderly Mexican Americans. Health Soc Work 1995;20:247-53.
38. Hunt LM, Jordan B, Irwin S, Browner CH. Compliance and the patient’s perspective: controlling symptoms in everyday life. Cult Med Psychiatry 1989;13:315-34.
39. Kleinman A. Patients and healers in the context of culture, Berkeley, Calif: University of California Press; 1980.
40. Brodwin P. Political contests and moral claims: religious pluralism and healing in a Haitian village. Boston, Mass: Harvard University; 1991.
41. Cosminsky S. Medical pluralism in Mesoamerica. In: Kendall C, ed. Heritage of conquest: thirty years later. Albuquerque, NM: University of New Mexico Press; 1983;159-73.
42. Cosminsky S, Scrimshaw M. Medical pluralism on a Guatemala plantation. Soc Sci Med 1980;14B:267-78.
43. Finkler K. A comparative study of health seekers: or, why do some people go to the doctor rather than to a spiritualist healer. Med Anthropol 1981;5:383-424.
44. Helman C. “Feed a cold, starve a fever” folk models of infection in an English suburban community, and their relation to medical treatment. Cult Med Psychiatry 1978;2:137.-
45. Higgins C. Integrative aspects of folk and Western medicine among urban poor of Oaxaca. Anthropol Q 1975;48:31-7.
46. Janzen J. The quest for therapy: medical pluralism in Lower Zaire. Berkeley, Calif: University of California Press: 1978.
47. Low S. Culture, politics and medicine in Costa Rica: an anthropological study of medical change. Bedford Hills, NY: Redgrave: 1985.
48. Nichter M. The layperson’s perception of medicine as perspective into the utilization of multiple therapy systems in the Indian context. Soc Sci Med 1980;14B:225-33.
49. Romanucci-Ross L. The hierarchy of resort in curative practices: the Admiralty Islands, Melanesia. J Health Soc Behav 1969;10:201-9.
50. Young J, Garro L. Variations in the choice of treatment in two Mexican communities. Soc Sci Med 1982;16:1453-65.
51. Norusis MJ. SPSS for Windows: base system user’s guide. Release 6.0. Chicago, Ill: SPSS Inc; 1993.
52. Hunt LM, Valenzuela MA, Pugh JA. “Porque me tocó a m1?”: Mexican American diabetes patients’ causal stories and their relationship to treatment behaviors. Soc Sci Med 1998;46:959-69.
53. Hunt LM, Valenzuela MA, Pugh JA. NIDDM patients’ fears and hopes about insulin therapy: the basis of patient reluctance. Diabetes Care 1996-7;20:292-8.
54. Hunt LM, Pugh JA, Valenzuela MA. How patients adapt diabetes self-care recommendations in everyday life. J Fam Pract 1998;46:207-15.
55. American Diabetes Association. Implications of the Diabetes Control and Complications Trial. Diabetes Care 1997;20(suppl):S62-4.
56. Roman-Ramos R, Flores-Saenz JL, Partida-Hernandez G, Lara-Lemus A, Alarcon-Aguilar F. Experimental study of the hypoglycemic effect of some antidiabetic plants. Arch Invest Med 1991;22:87-93.
57. De Tommasi N, De Simone F, Cirino G, Cicala C, Pizza C. Hypoglycemic effects of sesquiterpene glycosides and polyhydroxylated triterpenoids of Eriobotrya japonica. Planta Med 1991;57:414-6.
58. Noreen W, Wadood A, Hidayat HK, Wahid SA. Effect of Eriobotrya japonica on blood glucose levels of normal and alloxan-diabetic rabbits. Planta Med 1988;54:196-9.
59. Trejo-Gonzalez A, Gabriel-Ortiz G, Puebla-Perez AM, et al. A purified extract from prickly pear cactus (Opuntia fuliginosa) controls experimentally induced diabetes in rats. J Ethnopharmacol 1996;55:27-33.
60. Roman-Ramos R, Flores-Saenz JL, Alarcon-Aguilar FJ. Anti-hyperglycemic effect of some edible plants. J Ethnopharmacol 1995;48:25-32.
61. Frati AC, Xilotl Diaz N, Altamirano P, Ariza R, Lopez-Ledesma R. The effect of two sequential doses of Opuntia streptacantha upon glycemia. Arch Invest Med 1991;22:333-6.
62. Ibanez-Camacho R, Meckes-Lozoya M. Effect of a semipurified product obtained from Opuntia streptacantha L. (a cactus) on glycemia and triglyceridemia of rabbit. Arch Invest Med 1983;14:437-43.