Knowledge, Attitude, and Practice of Diabetic Patients toward Herbal Products in Iran: A Cross-sectional Study
Behrouz Talaei; PhD^1,2, Golaleh Asghari; PhD², Parvin Mirmiran; PhD^*2,
Fereidoun Azizi; PhD³ & Shohreh Bahreini; MSc^4
1 Department of Nutrition, School of Public Health, Kerman University of Medical Sciences, Kerman, Iran.
² Nutrition and Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
³Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
⁴ School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

iabetes mellitus is an important multifactorial public health disease with increasing incidence and prevalence worldwide. It afects the quality of life, leads to considerable complications, and impacts morbidity and mortality rates both in the developed and developing countries (Ebrahim and Smith, 2001, Larijani and Zahedi, 2002). National data show that the prevalence of diabetes in Iran is about 10%, which has increased over time (Esteghamati et al., 2007). The presence of a chronic illness such as diabetes has been documented as a reason for seeking out alternative medicines. Alternative medicine has a heterogeneous nature, and its use from hypnosis to herbal remedies / products (Ernst, 2000).
Traditional medicine is an accessible and affordable health care resource for many countries including countries of the Eastern Mediterranean region (World Health Organization, 2010). World Health Organization (WHO) recommendes use of traditional medicine / complementary and alternative  medicine (TM / CAM) therapies among the public and consumers (World Health Organization, 2011). Application of TM / CAM in the management of chronic diseases is well known in the developing countries; people commonly use herbal medicine products in self-care. Herbal medicines are also used in varying degrees with an increasing trend in industrialized countries (Al Saeedi et al., 2003, Barnes, 2003, Dutta et al., 2003, Zollman and Vickers, 1999). Increased use of TM / CAM has led to an increasing interest in how health professionals view these therapies (Bent and Ko, 2004, Calixto, 2000, Naidu et al., 2005). This can be due to the wide usage and low cost of these medicines as well as the fact that many physicians believe in the usefulness of alternative medicine (Hasan et al., 2000). Over 400 traditional herbal remedies were fund for diabetes, although limited scientific evaluations were conducted to evaluate their efficacies (Poss et al., 2003).
The hypoglycemic effect of some herbal products was assessed in human and animal models with type 2 diabetes (Yeh et al., 2003). Studies show that 50% of patients do not inform their physicians about their herbal supplement usage (Elder et al., 1997). Due to the adverse reactions and interactions between herbs and conventional drugs (Ernst and Pittler, 2002, Pinn, 2001), it is important to identify the perception of specific populations regarding consumption of herbal products and to determine if herbal products users routinely inform their primary care physicians about using these drugs. A previous review investigated the diabetic patients’ knowledge regarding the potential side effects of herbal medicines and their reasons to inform their physician about using this kind of drugs (Thomson et al., 2012a).
The present study was designed to determine the prevalence of herbal product usage and assess the related knowledge, attitude, and practice among patients with diabetes in Tehran, Iran.
Material and Methods
Participants: A total of 421, men (n = 157) and women (n = 244) aged ≥ 20 years were recruited in a period of five months during november 2014 to march 2015 from the Iran Diabetes Association in Tehran, Iran. All selected participants had diabetes under insulin or oral anti-diabetic drug therapy with modification in their diet for at least two months prior to the study based on the physician's prescription. Type 2 diabetes was defined according to the criteria set by the American Diabetes Association: individuals with fasting blood glucose levels of 7.0 mmol/L or higher or with 2-h post-75 g glucose loads of 11.1 mmol/L or higher as well as those under therapy for a definite diagnosis of diabetes were considered to have diabetes (Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, 2003).
Measurements: We designed and used a self‑administered questionnaire to collect the required data, including participnats' socio-demographic and knowledge, attitude, and practice (KAP) towards using herbal products. Data were collected from each participant under the supervision of trained nutrition experts.  The KAP questionnaire included five sections: 1) socio-demographic information (gender, age, material status, and education) and smoking status; 2) type, duration, presence of complications, and treatments of diabetes; 3) participants' knowledge on herbal products comprised of familiarity with various specific herbal products, effective and adverse effects of herbal products based on the physician's order or self-decision, substitution of conventional drugs with herbal medicines; 4) attitudes toward and beliefs about use of herbal products' consumption, and patients' consulting with their physician about herbal products' intake; 5) participants' practice such as frequency of herbal products use, sources and reasons of their use, the person who prescribed the medications, its side effects, patient satisfaction with the medications, concomitant use with a prescribed medicine, and if the patient informed his/her physician regarding the use of herbal treatment were investigated.
Data analysis: Data extracted from completed questionnaires were statistically analyzed using SPSS (version 15.0; SPSS, Chicago, IL, USA). We assessed the variables' normality using histogram charts and a Kolmogorov–Smirnov analysis, indicating that all variables had a normal distribution. Characteristics of the study paricipants were presented as mean ± SD for continuous variables and percentages for categorical variables. Chi-square was used to compare qualitative variables between participants based on gender. P-values < 0.05 were considered as statistically significant.
Ethical considerations: The study protocol was approved by the ethics committee of the Research Institute for Endocrine Sciences, affiliated to the Shahid Beheshti University of Medical Sciences, Tehran, Iran. Written informed consent was obtained from all participants.
Results
Socio-demographic and other characteristics of the study population: A total of 421 individuals participated in the study. Mean of age population was 38.0 ± 20.6 years. Of all paticipants, 55.4% were married, almost 35% had academic education, and approximately 52.2% of paticipants were employed (Table 1). Our findings indicated that most participants obtained their necessary medical information from books and media (54.60%) and their physicians (34.87%). Men and women did not differ significantly according to age, educational levels, marital status, source of obtaining medical information, type of diabetes, type of medications used for diabetes (anti-diabetic drugs or insulin injection), and history of diabetes. However, smoking was higher among males compared to females.
Knowledge of participants about using herbal products: Participants' knowledge about using herbal products as a treatment for controlling diabetes and its difference with conventional treatments is presented in Table 2. Half of the participants did not have any knowledge about herbal medicine as a treatment of diabetes. Of all participants, 42.7% declared that using herbal products as a treatment, instead of conventional anti-diabetic drugs, was not suitable; however, 43.4% of them did not have knowledge on this topic. Overall, most participants (62.2%) were not aware of about probable complications of concomitant use of herbal products with conventional anti-diabetic drugs. However, 71.6% of participants stated that using herbal products, without physician's prescription was not permissible. In addition, most participants (67.6%) did not have knowledge about the following question: “is the sale of herbal products in pharmacies with industrial packaging legally allowed by the ministry of health?”
Compared to females, males responded more positively than females to this question: "Can herbal products be used instead of conventional anti-diabetic drugs?" (20.3% in males vs. 10.3% in females, P = 0.001). Furthermore, compared to females, more males reported that they did not have knowledge about the possibility of using herbal products, without physician's prescription (33.3% in males vs. 21.2% in females, P  =  0.008).
Participants' attitude toward herbal products: Almost 33.8% of participants disagreed that herbal products were more effective than conventional anti-diabetic drugs, while 47% had no idea about this issue (Table 3). Considering complications of herbal products, 60% of participnats mentioned that herbal products had lower complications in comparison to conventional anti-diabetic drugs. Furthermore, most participants (53.0%) believed even herbal products did not have benefits, at least they were harmless. However, most participants (59.3%) disagreed to use herbal products without physician prescription.
A significant difference was observed between male and female respondents regarding some aspects of the herbal products' application (Table 3). Our results indicated that males, more than females, agreed with greater effectiveness of herbal drugs in comparison to conventional anti-diabetic drugs (25.0% in males vs. 15.4% in females, P = 0.004). Moreover, more males agreed that herbal products had less complications than conventional anti-diabetic drugs (69.1% in males vs. 55.8% in females, P = 0.004). However, compared to men, women disagreed with the idea that "even if the herbal products do not have benefits, at least they are harmless" (23.0% in women vs. 8.6% in men, P = 0.003). Women also disagreed more with using herbal products instead of conventional anti-diabetic drugs (45.9% in women vs. 30.3% in men, P = 0.023). Finally, more women believed that using herbal products, without a physician's prescription was incorrect and inappropriate (64.0% in women vs. 52.7% in men, P = 0.023).
Participants' practice regarding herbal products:
Table 4 shows the participnats' practices regarding use of herbal products in the study population. Results showed that over two-thirds of participants used herbal medicines rarely (70.9%) and participants who consumed herbal products daily or weekly were rare (8.4%). No difference was found between men and women regarding the frequency of consuming herbal products. More than half of th participants used herbal products with physician's prescription (57.8%), while self‑decision making was the weakest reason in consuming herbal products among the particinats (15.8%). Females, more than males, used herbal products according to the physician's prescription (65% in females vs. 45.5% in males, P < 0.001). Over 75% of particinats used only conventional anti-diabetic drugs therapy to treat or control their diabetes (80.4%) and only less than 2% of the participants used herbal products as a treatment for controlling diabetes. Nearly 90% of all individuals declared that they did not use herbal products without physicians' prescription for the treating or controlling diabetes or other chronic diseases such as hypertension. Most participants informed their physicians if they decided to use herbal products (64.4%) and no significant difference was found among males and females. Furthermore, more than 65% of all participants did not use the herbal products along with the conventional anti-diabetic treatments.