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Fattahi Ardakani M, Namiranian N, Afkhami Ardekani M, Zareipour M, Asadian A, Heydari S. Consumption of Medicinal Plants among Patients with Diabetes in Eastern Mediterranean Regional Office Countries: A Systematic Review and Meta-Analysis. JNFS 2024; 9 (1) :116-131
URL: http://jnfs.ssu.ac.ir/article-1-797-en.html
Consumption of Medicinal Plants among Patients with Diabetes in Eastern Mediterranean Regional Office Countries: A Systematic Review and Meta-Analysis
Mojtaba Fattahi Ardakani , Nasim Namiranian , Mohammad Afkhami Ardekani , Moradali Zareipour * , Ali Asadian , Sara Heydari
Department of Public Health, School of Health, Khoy University of Medical Sciences, Khoy, Iran
Keywords: Systematic review, Diabetes mellitus, Complementary therapies, Plants, Medicinal
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Consumption of Medicinal Plants among Patients with Diabetes in
Eastern Mediterranean Regional Office Countries: A Systematic
Review and Meta-Analysis

Mojtaba Fattahi Ardakani; PhD1, Nasim Namiranian; PhD2, Mohammad Afkhami Ardekani; MD2,3, Moradali Zareipour; PhD*4, Ali Asadian; PhD5 & Sara Heydari; PhD1
1  Shahid Sadoughi University of Medical Sciences, Yazd, Iran; 2 Yazd Diabetes Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran; 3 Department of Internal Medicine, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran; 4 Department of Public Health, School of Health, Khoy University of Medical Sciences, Khoy, Iran; 5 Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
ARTICLE INFO ABSTRACT
SYSTEMATIC REVIEW and META-ANALYSIS Background: Diabetes mellitus is a chronic disease which affects all aspects of human life. Medical herbs have become increasingly popular as complementary therapeutic measures for patients with diabetes. Thus, the present research aims to explore the consumption of medical herbs in patients with diabetes in Eastern Mediterranean Regional Office (EMRO) countries through a meta-analysis. Methods: The following keywords were searched: medicine, medicinal plants, healing plants, medicinal herbs, use, usage, frequency of use, prevalence, diabetes patients, type 2 diabetes, adults with diabetes, and EMRO countries. The databases searched included Scopus, PubMed, Web of Science, and Google Scholar. Results: A total of 3,542 papers were found. After omitting repeated or irrelevant papers, 70 papers were retained. An analysis of the abstract and full text of papers led to the retention of 35 papers. A great variance was found regarding the rate of consuming medical herbs in the papers (16.8-97.7%). The relative frequency of consuming medical herbs was 38% (95% CI: 33-44). Moreover, the most prevalent herbs were fenugreek (19%), cinnamon (18%), black seed (14%), white lupinus (13%), and olive (13%) with a 95% confidence interval. About 70% of patients (95%CI: 62-79) did not inform their physician of their herbal medicine consumption. Conclusion: In light of the present findings, it can be concluded that patients with diabetes use a wide range of medical herbs. Thus, health specialists and physicians need to be aware of the possible synergic or moderating effect of herbal medicine on the therapeutic measures taken for diabetes.
Keywords: Systematic review; Diabetes mellitus; Complementary therapies; Plants; Medicinal
Article history:
Received: 26 Dec 2022
Revised: 21 Feb 2023
Accepted:5 Mar 2023
*Corresponding author:
    Zareipoor_m@khoyums.ac.ir
Department of Public Health, School of Health, Khoy University of Medical Sciences, Khoy, Iran
Postal code: 58167-53464
Tel: +98 9141878294

Introduction
The World Health Organization (WHO) estimated that more than 400 million people worldwide have diabetes (Association, 2013). The International Diabetes Federation also estimated the total number of diabetic patients in 2040 to be about 690 million (Saeedi et al., 2019). Poor management of this disease can cause serious and even fatal problems such as cardiovascular diseases, renal disease, neuropathy, and retinopathy (Nentwich and Ulbig, 2015, Singla, 2022). Diabetes mellitus is a chronic disease in carbohydrate metabolism which increases the level of blood glucose in the long run (Poretsky, 2010). The prevalence of diabetes type II is significantly high in Eastern Mediterranean Regional Office (EMRO) countries (Mirahmadizadeh et al., 2020) located near the Persian Gulf, as well as several other countries such as Tunisia, Libya, Egypt, Morocco, Sudan, Lebanon, Palestine, and Pakistan. Thus, an important goal in EMRO countries (as in many other countries worldwide) is to lower the population of patients in forthcoming years (World Health Organization, 2006). Controlling blood sugar requires self-care behaviors such as diabetic self-management. Self-management involves adherence to prescribed medicine and clinical procedures, adoption of a healthy lifestyle, and a healthy diet for a given disease (Mirahmadizadeh et al., 2020).
In recent years, with the advent of advanced therapeutic measures and new medications, patients have welcomed medical herbs besides the commonly prescribed medicines to control their disease (Azaizeh et al., 2003, Baldé et al., 2006, Guarrera, 1999). Some patients used medical herbs as the only cure for their disease, while others used them together with other common medicines (Amaeze et al., 2018, Özkum et al., 2013). As related studies have revealed, patients have different reasons for their preference for medical herbs, including failure to control the disease with common medicines, adverse effects, high cost, and limited access. Moreover, belief in the efficiency of medical herbs has added to the growing popularity of medical herbs among patients (Aydin et al., 2008, Ondicho et al., 2016). Many studies have been conducted on the effectiveness of medicinal herbs in controlling diabetes, which can further point to the significance of consuming these medicines in controlling the disease (Ernst, 2005, Lu et al., 2019, Mozaffari-Khosravi et al., 2009).
Due to the ever-increasing willingness of patients with diabetes to use complementary medicine, many studies have also been conducted to explore its prevalence in different countries (Amaeze et al., 2018, Ching et al., 2013, Da-Yong and Ting-Ren, 2019). In a review conducted in EMRO, the prevalence rate of complementary and alternative medicine was reported to be 37% among patients with diabetes. This review only explored complementary and alternative medicine in general ,and did not investigate the rate of consuming medical herbs as one of the most common complementary medicines (Adib-Hajbaghery et al., 2021). Thus, considering the significance of EMRO countries in the population of diabetic patients, it is essential to explore the most common herbal medicines in these countries. As a result, the present research aims to explore the prevalence of consuming medical herbs in EMRO countries in a purposive and structured manner.
Materials and Methods
The present meta-analytic and systematic review was designed in accordance with the guidelines for systematic reviews and meta-analyses (Moher et al., 2015). This systematic protocol was developed according to PRISMA guidelines (#CRD42020142463).
Search strategies: To identify studies pertaining to herbal medicine, related countries, and frequency of use features in patients with Type 2 diabetes, the authors systematically searched PubMed, Web of Science, Scopus, Google Scholar and Information Foundation databases for significant articles published through April 30, 2021. The references of the downloaded articles were also reviewed to identify additional studies. Search terms were as follows: medicinal plants, healing plants, medicinal herbs, use, usage, frequency of use, prevalence, diabetes patients, type 2 diabetes, adults with diabetes, EMRO countries.
Inclusion criteria: The researchers included published papers (cohort studies, cross-sectional reports) which provided available data about demographic information, medicinal herb use, and related EMRO countries features in patients with Type 2 diabetes. The statistical population was defined above 18, and no language limit was set. The studies which did not report original data and had no relevant outcome were excluded.
Paper selection: Screening and selecting the relevant papers were done by two researchers independently (henceforth abbreviated as Namiranian N and Afkhami Ardekani M). The screening process was hierarchical and included reading the title, abstract, and full text of papers. Thus, the relevant papers were found step by step. The most relevant papers were retained at the end after the irrelevant papers were excluded. Additionally, the relevant references in each paper were scrutinized to be included in the final retained papers.
Data extraction and quality assessment: The required data were extracted regarding the features of studies, the prevalence of using medicinal herbs, and types of medicinal herbs consumed by patients with diabetes. The qualitative analysis was done by three independent authors (Afkhami Ardekani M, Heydari S and Zareipour M). In case there was a disagreement in scoring an item, the final decision was made by the first author. The instrument used for the qualitative analysis of papers was derived from the related literature on complementary and alternative medicine (James et al., 2018). The papers were finally categorized into three groups: high-quality (7-10), moderate-quality (3-7), and low-quality (0-3). In the instrument used, the papers were evaluated according to their methodology, participants, and an accurate conceptualization of complementary medicine in methodology. If a paper was assigned to the low-quality group, its results were not included in the analysis. The scoring system is summarized in Table 1.
Data analysis and synthesis: The frequency of consuming medical herbs by patients with diabetes was extracted from related papers as reported in percentages. The rate of consuming medical herbs was then derived from the literature at a 95% confidence interval. A meta-analysis was conducted to explore the rate of consuming herbs in EMRO countries via a random effects model (Moher et al., 2015). The assumption was that the effect size (relative frequency) would vary between different studies, so a fixed effect model was deemed inappropriate (James et al., 2018); Steel, & Adams). Data analysis was performed using the comprehensive meta-analysis software (version 2.2.064). The I2, T2 and Q indices were used to test the heterogeneity of the papers. The first index indicates statistical significance, while the other two show the effect size of heterogeneity. An inverse method was used to estimate variance and weights in each paper. P-values below 0.05 were considered statistically significant.
Results
A total of 3,542 papers were initially analyzed in this study, and ultimately, 35 papers met the inclusion criteria, with details summarized in Figure 1. After qualitative analysis, papers were divided into three groups: 17 papers were assigned to the high-quality group, 18 to the moderate-quality group, and none to the low-quality group. The detailed analysis results can be found in
Table 2.
Features of papers: Papers were from 23 countries, 8 from Saudi Arabia, 1 from Bahrain, 1 from Egypt, 1 from Lebanon, 1 from Palestine, 1 from Libya, 8 from Iran, 1 from Oman, 4 from Morocco, 1 from Tunisia, 3 from Jordan, 1 from Pakistan, 1 from United Arab Emirates, 1 from Sudan and 2 from Iraq. The majority of the studies were conducted in Iran and Saudi Arabia.
Overall, 15,751 diabetic patients participated in this study, with 6,189 using medical herbs to control their disease. Participants were often found in diabetes clinics and healthcare centers, most of whom acquired their knowledge of medical herbs from family and friends.
Table 1. The quality scoring system.
Dimensions Items Point awarded
Methodology






Representative sampling strategy Yes 1
No 0
Sample size>500 Yes 1
No 0
Response rate >75 % Yes 1
No 0
Low recall bias Yes 1
No 0
Participants’ characteristics







 Age Yes 1
No 0
Inclusion of both genders Yes 1
No 0
Residence location Yes 1
No 0
Socioeconomic status Yes 1
No 0
Health status Yes 1
No 0
CM use/definition CM use/definition Yes 1
No 0
Frequency of consuming medical herbs: The frequency of consuming medical herbs ranged from 16.8% to 97.7% in the papers. The highest prevalence of medical herb consumption was reported in 2 papers from Iran, being 97.7% and 88.4%, respectively (Al-Kindi et al., 2011, Eddouks et al., 2002, Salih and Al-Asadi, 2012). The next highest rate was found in studies from Morocco and Oman, 80% and 79%, respectively (Al-Kindi et al., 2011, Eddouks et al., 2002). The lowest frequency of consuming medical herbs was found in studies from Oman and Iraq, with rates of 16.6% and 17.3% (Al-Kindi et al., 2011, Salih and Al-Asadi, 2012). These features are summarized in Table 3. The overall prevalence of these medicinal herbs, as the analysis showed, was 38%, 95%CI: 33-44, Figure 2). The estimated Q was 1,676 with a degree of freedom of 34 and a P<.0001. Moreover, T2=0.53 and I2=97 indicated that about 97% of the observed variance in the papers was true. This suggested a wide range of divergence in the prevalence of consuming medical herbs in the papers (16.8-97.7%). As can be observed in Figure 3, significant heterogeneity could be seen among the papers.
The Rate of informing physicians regarding consuming medical herbs: Table 3 presents the extent to which diabetic patients informed their physician of their rate of consuming medical herbs. The relative frequency of not informing physicians about their herb consumption was 70 (95% CI,
62-79%).
Prevalent herbs: The most prevalent herbs were fenugreek (19%, 95% CI, 14-26%), cinnamon (18%, 95% CI, 11-27%), black seed (14%, 95% CI, 10-20%), white lupinus (13%, 95%CI, 6-24%), olive (13%, 95% CI, 7-23%), and ginger (12%, 95% CI, 7-20%). Details on the other medical herbs and the frequency of their use (Talaei et al., 2019) are included in Table 4.
 
Table 2. Characteristics of the included papers.
Score
(0-10)		 CM
definition		 Participants Methodology Author, year
Health
status		 Socioeconomic
status		 Residence
location		 Gender Age Low recall
bias		 Response rate
>75 %		 Sample
size>500		 Representative
sampling method
6 No Yes Yes No Yes Yes No Yes No Yes (Al-Garni et al., 2017)
9 Yes Yes Yes No Yes Yes Yes Yes Yes Yes (Ali and Mahfouz, 2014)
6 Yes Yes No No Yes Yes No Yes No Yes (Alqathama et al., 2020)
4 Yes No No No Yes Yes No Yes No No (Alsanad et al., 2018)
7 Yes No No Yes Yes Yes Yes Yes No Yes (Talaei et al., 2019)
6 Yes No No Yes Yes Yes No Yes Yes No (Boufous et al., 2017)
7 Yes No No Yes Yes Yes Yes Yes Yes No (Eddouks et al., 2002)  .
7 Yes No No No Yes Yes Yes Yes Yes Yes (Jafari et al., 2021)
5 No No No yes yes yes yes yes No No (Khuttar and Jallab, 2020)
6 Yes No No yes yes yes yes Yes No No (Otoom et al., 2006)
9 Yes Yes Yes Yes Yes Yes NO Yes Yes Yes (El-Dahiyat et al., 2020)
9 yes yes yes yes yes yes yes Yes No Yes (Radwan et al., 2020)
5 Yes No No No Yes Yes Yes Yes No No (Al-Rowais, 2002b)
7 No Yes No No Yes Yes Yes Yes Yes Yes (Al Saeedi et al., 2003)
7 No No Yes Yes Yes Yes Yes Yes No Yes (Awad et al., 2008)
5 Yes No No No Yes Yes No Yes No Yes (Khalaf and Whitford, 2010)
7 No No No Yes Yes Yes Yes Yes Yes Yes (Ali-Shtayeh et al., 2012)
6 Yes Yes No No Yes Yes Yes Yes No No (Al-Kindi et al., 2011)
7 No No No Yes Yes Yes Yes Yes Yes Yes (Wazaify et al., 2011).
9 Yes No Yes Yes Yes Yes No Yes Yes Yes (Salih and Al-Asadi, 2012)
6 Yes No No No Yes Yes Yes Yes NO Yes (Khalil et al., 2013)
4 No No No No Yes Yes Yes Yes No NO (Algothamy et al., 2014)
5 No Yes No Yes Yes Yes No Yes No NO (Naja et al., 2014)
6 No Yes NO Yes Yes Yes Yes Yes NO NO (Alami et al., 2015)
7 Yes Yes NO Yes Yes Yes Yes Yes NO NO (Hashempur et al., 2015)
9 No Yes Yes Yes Yes Yes Yes Yes Yes Yes (Azizi-Fini et al., 2016)
4 No Yes NO NO Yes Yes Yes NO NO NO (Kamel et al., 2017)
6 No Yes No No Yes Yes Yes Yes NO Yes (Al-Eidi et al., 2016)
8 Yes Yes Yes Yes Yes Yes NO Yes NO Yes (Yousofpour et al., 2016)
7 No Yes Yes Yes Yes Yes NO Yes Yes NO (Ashur et al., 2017)
7 yes Yes Yes Yes Yes Yes NO yes NO Yes (Sheikhrabori et al., 2017)
8 No Yes Yes Yes yes yes yes yes NO Yes (Othman et al., 2013)
6 No Yes Yes NO yes yes yes yes NO No (Jawed et al., 2019)
9 yes yes yes yes yes yes yes yes NO Yes (Sabery et al., 2019).
5 NO NO NO yes yes yes NO Yes Yes NO (Jouad et al., 2001)
8 Yes NO NO yes yes yes Yes Yes NO Yes (Wazaify et al., 2013).
Table 3. Features of the included papers in the reviews.
Physician's awareness of usage The main herb used Prevalence
(%)		 Mean
duration		 Mean
age±SD		 Sample
size(RR)		 Country Author /year
27% Myrrh:45%, black seed:19.3%, helteet:13.7%, , Fenugreek:13.7%  
9.8aloes:11.8%,artemesia:		 17.4 Not reported 51.99±15.66 300(98.6) Saudi Arabia (Al-Rowais, 2002b)
Not reported Ammi visnaga, artemesia herba alba, fenugreek, marrubium vulgare, nigella sativa 800 Not reported Not reported 320 Morocco (Eddouks et al., 2002)
Not reported Fenugreek(6.1%),chinaberry (5.1%)
rhazia strica(4.8%)		 30.1 5Years>287
787>5Years		 Not reported 1039 (89.5) Saudi Arabia (Al Saeedi et al., 2003) .
80% Fenugreek (22.9%), lupinus albus (14.6%), garlic(11.5%), onion (9.8%),eucalyptus (9.4%), 31.0 10.5 ± 6.9 Not reported 300(-) Jordan (Otoom et al., 2006)
45% Garlic (36%), bitter melon(31%)
cinnamon (30%) and fenugreek (27%).		 64.0 Not reported Not reported 402(63%) Bahrain (Khalaf and Whitford, 2010)
32% Fenugreek(19.6%), rosemary (13.5%),olive (13.4%), teucrium capitatum lamiaceae) (11.4%), and cinnamomum (10.8%) 51.9 Not reported 79.6%>40 1883(-) Palestine (Ali-Shtayeh et al., 2012)
13% Harmel:10%,fenugreek:8% , black seeds and nigella sativa:6% 79.0 8.48±6.5 Not
Reported		 146(100) Oman (Al-Kindi et al., 2011).
15.7% Green tea:20.5, aniseed:19.9%, ginger:18.7%,chamomile:18.1%,sage:15.6, fenugreek (10.8) 16.6 Not reported Not
Reported		 1000(100) Jordan (Wazaify et al., 2011).
5.9% Cinnamomum:12.4%,black seed:11.1%,garlic:6.5%,alo vera:3.9%, enugreek:3.3% 17.3 Not
reported		 50.9±13.1 884(89.6) Iraq (Salih and Al-Asadi, 2012).
21% White lupine:42.9%,fenugreek:42.5%
onion:34.4%,nigella sativa:7.8%		 41.7 Not reported Not Reported 1100(100) Egypt (Khalil et al., 2013)
Not reported Gum arabic(louben) (71.7%),fenugreek (28.3%) of white artemisia (21.7%) and marrube (10.9%) 23.0 10.5 ± 6.9 Not Reported 200 Tunisia (Othman et al., 2013).
Not reported Not reported 32.1 Not reported Not reported 226(93.1) Jordan (Wazaify et al., 2013).
33.9% Fenugreek (57.1%),black seed(44.6%), myrrh(42.9%), Garlic(32.1%) 24.6 Not reported Not Reported 228(86) Saudi Arabia (Algothamy et al., 2014).
7% Not reported 37.0 Not reported 60.29±11.89 333(94.6) Lebonon (Naja et al., 2014)
Fenugreek (29.1%), black seed (21.6%)
cinnamon (16.8%) and olive (15.7%)		 58.0 Not reported 49%(41-50) 600 Sudan (Ali and Mahfouz, 2014)
Not reported Sage (n=62),fenugreek(n=36),olive(n=34)
artemisia herba-alba(n=32), origanum compactum(n=28),rosemary (n=14)		 54.8 7 50±17 279 Morocco (Alami et al., 2015).
Not reported Cinnamon:50.1,ginger:30.2,fenugreek:18.8 97.7 Not reported 51.9 ±15.6 239 Iran (Hashempur et al., 2015)
38.1% Cinnamon:120(24.7),nettle 59 (12.2), fenugreek 48 (9.9),walnut 36 (7.5),garlic 33 (6.8), green tea 30 (6.2)
chicory 29 (6.0),ginger 28 (5.9		 54.0 10.24±7.10 56.88±10.7 500(87.7) Iran (Azizi-Fini et al., 2016).
38.3% black seeds (27%), myrrh (20.3%), fenugreek (15.2%), and aloe (10.8%). 62.0 6.5 ± 4.6 51.6 ± 10.6 300(71.3) Saudi Arabia (Kamel et al., 2017).
Not  reported Not reported
 30.4 Not reported 40-60 302(100) Saudi Arabia (Al-Eidi et al., 2016)
36.4% nettle (n=48), fenugreek(n=24), barberry(n=13), cinnamon(14), and green tea(11) 36.6 9.8±7.3 56.2±10.1 270(100) Iran (Yousofpour et al., 2016).
Not  reported Ginger (11.6%), black seed (10%), cinnamon (5.5%), fenugreek (2.9%), garlic (2.9%) 25.8 64.8%(5-10) 57.58±8.50 310(100) Saudi Arabia (Al-Garni et al., 2017)
Not  reported Frankincense:19.3%,olive leaves:11.9%
green tea:26.6%,onion:18.9%,garlic:16.8%		 59.9 Not Reported 54.43±10.03 523(100) Lybia (Ashur et al., 2017).
Not  reported Nigellasativa, fenugreek, artemisia huguetii L., garlic 35.9 Not Reported Not Reported 358 Morocco (Boufous et al., 2017)
44.2% Chamomile(39.5%),green tea:17.74
 88.4 6.38 + 4.76 47.87 + 11.89 294(100) Iran (Sheikhrabori et al., 2017).
Not reported Not  reported 48.0 Not Reported 51.5 + 14.8 400(100) Pakistan (Jawed et al., 2019)
57.8% Not  reported 70.9 Not reported 38.0 ± 20.6 421(100) Iran (Talaei et al., 2019)
Not reported Fenugreek (15.4%), sage (13.3%) and olive (10.8%). 53.6 61.2%(16-30) 334(100) Morocco (Skalli et al., 2019)
Not reported Fenugreek 71.6 Not Reported
 Not Reported 296(100) Iran (Sabery et al., 2019).
49% Olive leaf (21.2%), green tea (21.2%), cinnamon (21.2%), black seeds (15.2%), and fenugreek (15.2%). 33.6 51-60(39%)
41-50(30.6%)		 98 Saudi Arabia (Alsanad, 2020)
Not Reported Not reported 76.2 Not Reported Not Reported 500(80) Jordan (El-Dahiyat et al., 2020)
29.6% Cinnamon (23.1%), ginger (19.2%), fenugreek (9.3%) 24.8 10>56.4%
1-5:21%		 46–60(51.3%) 309(96.4) Saudi Arabia (Alqathama et al., 2020)
88.1% Not  reported 24.6 61.9≥year 11
38.1≥10		 55.8±12.5 244(80) United Arab Emirates (Radwan et al., 2020)
3.8% Herbal tea 20 (37.7 %), cinnamon 28 (52.8 %)
olive oil 6 (11.3 %), nigella sativa 10 (18.9 %),
ginger 7 (13.2 %)		 53.0 9.61 ±6.88 51.04 ±16.90 100(100) Iraq (Khuttar and Jallab, 2020)
58.6% Not  reported 21.9 42.3%(6-10) 49.08±8.03 1000 Iran (Jafari et al., 2021)
Table 4. The most common medicinal herbs and their prevalence in EMRO countries.
Medical herb Prevalence
and range (%)		 n. of
studies		 The country with the highest consuming rate
English name Scientific name
Fenugreek Triognella foenum 19(14-26) 20 Saudi Arabia, Iran, Egypt, Jordan, Iraq, Morocco, Sudan, Palestine, Tunisia 
Black seed Nigella sativa L. 14(10-20) 16 Saudi Arabia, Libya, Egypt, Iraq, Jordan, Morocco, Palestine
Cinnamon Cinnamomum zeylanicum blume. 18(11-27) 14 Saudi Arabia, Iran, Iraq, Morocco
Ginger Zingiber officinale rose 12(7-20) 8 Saudi Arabia, Iran, Iraq, Morocco, Sudan, Palestine
Garlic Allium sativum L. (liliaceae) 9(4-19) 12 Saudi Arabia, Iran, Egypt, Jordan, Iraq, Morocco, Sudan, Palestine
Aloe Aloe vera (L.) Burm. f. (Xanthorrhoeaceae) 9(3-22) 9 Saudi Arabia, Libya, Iraq, Morocco, Palestine, Tunisia
lupine Lupinus albus L. (Fabaceae) 13(6-24) 9 Saudi Arabia, Libya, Egypt, Jordan, Morocco, Palestine
Green tea Camellia sinensis (L.) Kuntze 10(4-20) 10 Saudi Arabia, Libya, Iran, Sudan, Palestine
Olive Olea europaea L 13(7-23) 10 Saudi Arabia, Libya, Iraq, Jordan, Morocco, Iran, Palestine
Onion Allium ceppa 8(3-17) 11 Saudi Arabia, Libya, Egypt, Jordan, Morocco, Palestine
Sage Salvia officianalis 9(5-14) 8 Tunisia, Saudi Arabia, Morocco, Palestine, Iraq
 
Discussion
The aim of this research was to explore the prevalence of consuming medical herbs in EMRO countries. The results showed that the prevalence rate ranged between 16.6% and 97.7%. Based on meta-analysis, the prevalence rate was 39%. A wide range of factors can affect the result. For instance, in Saudi Arabia, Al-Rowais (Al-Rowais, 2002b)  reported a rate of 17.4% among diabetic patients, while Kamel (Kamel et al., 2017) reported a rate of 62%. These results were consistent with the findings ofa review from South African countries, with a rate of 77% in Tanzania and 12.7% in Kenya (James et al., 2018). The widely varying consumption rates can be attributed to variables such as the duration of the affliction, education, place of residence, and even the location of the interview that diverged across studies. In several studies, age and education were correlated with the consumption of medical herbs (El-Dahiyat et al., 2020, Otoom et al., 2006) . This finding was not reported in any other study or was not statistically significant (Alsanad, 2020, Jafari et al., 2021, Radwan et al., 2020) . The location of the interview was another factor which could affect the self-report of medical herb consumption. In studies with participants selected from hospital clinics, the rate of consuming medical herbs was low. However, in the body of research related to diabetic patients, a higher rate of consuming medical herbs was reported. This finding can be due to the patient’s health and adherence to medical advice, which requires further research (Al-Rowais, 2002a, Al Saeedi et al., 2003, Alsanad, 2020). Different sample sizes, inclusion criteria, data collection methods, and the duration of consuming medical herbs (lifelong, within the past year, or for a certain time before the research) were among other factors which can account for different research findings. In several studies, the rate of consuming medical herbs was explored with only one question (“Have you consumed medical herbs within the past year?) (Al Saeedi et al., 2003, Awad et al., 2008, Hikaambo et al., 2022, Otoom et al., 2006). Using only one question to determine the extent to which a patient used medical herbs within the past year can cause a recall bias. The present study aimed to explore the prevalence of consuming medical herbs in EMRO countries.
A review of consuming medical herbs in Arabic countries showed that about 60-80% of people used local medical herbs to control and treat diseases. Thus, they experience physical and mental effects too, and the effectiveness of some of the herbs had not even been proven (Ali-Shtayeh et al., 2012). A high percentage of patients consumed medical herbs without any physician’s advice. The reasons for this could be ineffective physician-patient communication, no recommendation by the physician, underestimation of consuming medical herbs by the physician, and the fear of blame by the physician (Al-Kindi et al., 2011). Therefore, patients should be made aware of the effectiveness, adverse effects, and indications of medical herbs with the help of physicians (Boufous et al., 2017). Physicians must also consider the role of culture, traditions, and values in patients’ tendency to consume medical herbs and other complementary and alternative medicines (Wazaify et al., 2011). Considering the popularity of medical herbs, healthcare systems and organizations need to take them seriously and take necessary measures to increase the effectiveness of therapeutic methods. The present research showed that the most common medical herbs in the target countries were fenugreek, black seed, and cinnamon. These medicines have also been prevalent in South Asian countries (Al-Asadi and Salih, 2012). The effectiveness of fenugreek, black seed (James et al., 2018), ginger (Talaei et al., 2019) , olive oil,  and cinnamon (Khalil et al., 2013) has also been confirmed in meta-analytic studies. However, several studies have reported that their consumption has been followed by increased sensitivity to insulin. Therefore, consuming these medicines alone to cure a disease should be done with care.
This study had several strengths. In order to include cross-sectional studies, the researchers considered an approximate use of medicinal herbs to reform prevalence, providing the opportunity to estimate the prevalence of medicinal herbs in all relevant studies. All the published literatures on the topic were comprehensively reviewed and three independent reviewers were asked to select and evaluate the quality of the studies. All of information used in analysis came from high quality and average publications. Limitations in this review should also be taken into account as below. Most of the study information came from publications, incomplete reporting of health status. Thus, some studies did not report the sequence generation of randomization.
Conclusions
Willingness to consume medical herbs is high in EMRO countries, as it is in many other countries. Therefore, consuming these herbs requires special attention. Belief in the harmlessness and effectiveness of medical herbs in controlling diseases is one of the reasons for their popularity. Moreover, local herbs were the most frequently consumed ones. About half of diabetic patients consumed these herbs on a daily basis to control diabetes. There is no comprehensive information on the exact percentage of patients who consumed these herbs alone or in combination with prescribed medication. As patients often do not inform physicians about consuming medical herbs, physicians need to be aware of the risks. Thus, more research is suggested on the prevalence of medical herbs to raise physicians’ awareness of therapeutic measures and the significant role they can play in managing the disease. A better control of the disease can help promote the quality of care and the quality of patients’ life.
Acknowledgements
The authors would like to express their gratitude to Shahid Sadoughi University of Medical Sciences and the Diabetes Research Center for their support.
Conflict of interest
The authors declared no conflict of interest.
Authors' contributions
Fattahi Ardakani M, Namiranian N, and Afkhami Ardekani M designed the study. Zareipour  M, Fattahi Ardakani M, and Heydari S contributed to gathering data, Fattahi Ardakani M, Zareipour M, Heydari S, wrote manuscript and analyzed the data. All authors read and approved manuscript for publication.
References
Adib-Hajbaghery M, Ardakani MF, Sotoudeh A & Asadian A 2021. Prevalence of complementary and alternative medicine (CAM) among diabetic patients in Eastern Mediterranean country members of the World Health Organization (WHO): A review. Journal of herbal medicine. 29: 100476.
Al-Asadi JN & Salih N 2012. Herbal remedies use among diabetic patients in Nassyria, Iraq. Middle East journal of family medicine. 10: 40-46.
Al-Eidi S, et al. 2016. Knowledge, attitude and practice of patients with type 2 diabetes mellitus towards complementary and alternative medicine. Journal of integrative medicine. 14 (3): 187-196.
Al-Garni A, Al-Raddadi R & Al-Amri T 2017. Patterns and determinants of complementary and alternative medicine use among type 2 diabetic patients in a diabetic center in Saudi Arabia: herbal alternative use in type 2 diabetes. Journal of fundamental and applied sciences. 9: 1738-1748.
Al-Kindi RM, Al-Mushrafi M, Al-Rabaani M & Al-Zakwani I 2011. Complementary and alternative medicine use among adults with diabetes in Muscat region, Oman. Sultan Qaboos University Medical Journal. 11 (1): 62.
Al-Rowais NA 2002a. Herbal medicine in the treatment of diabetes mellitus. Saudi medical journal. 23 (11): 1327-1331.
Al-Rowais NA 2002b. Herbal medicine in the treatment of diabetes mellitus. Saudi medical journal. 23 (11): 1327-1331.
Al Saeedi M, El Zubier A, Bahnassi A & Al Dawood K 2003. Patterns of belief and use of traditional remedies by diabetic patients in Mecca, Saudi Arabia. Eastern Mediterranean health journal. 9 ((1-2)): 99-107.
Alami Z, Aynaou H, Alami B, Hdidou Y & Latrech H 2015. Herbal medicines use among diabetic patients in Oriental Morocco. Journal of pharmacognosy and phytotherapy. 7 (2): 9-17.
Algothamy AS, et al. 2014. Prevalence of using herbal drugs as anti-diabetic agents in Taif Area, Kingdom of Saudi Arabia. Saudi journal for health sciences. 3 (3): 137-140.
Ali-Shtayeh MS, Jamous RM & Jamous RM 2012. Complementary and alternative medicine use amongst Palestinian diabetic patients. Complementary therapies in clinical practice. 18 (1): 16-21.
Ali BAM & Mahfouz MS 2014. Herbal medicine use among patients with type 2 diabetes in North Sudan. Annual research & review in biology. 19: 1827-1838.
Alqathama A, et al. 2020. Herbal medicine from the perspective of type II diabetic patients and physicians: what is the relationship? BMC complementary medicine and therapies. 20 (1): 1-9.
Alsanad S, Aboushanab T, Khalil M & Alkhamees OA 2018. A Descriptive Review of the Prevalence and Usage of Traditional and Complementary Medicine among Saudi Diabetic Patients. Scientifica.
Alsanad SM 2020. Usage Assessment of Complementary and Alternative Medicine in Saudi Diabetic Patients. International journal of pharmaceutical sciences and research. 11 (4): 1941-1948.
Amaeze OU, et al. 2018. Herbal medicine use among type 2 diabetes mellitus patients in Nigeria: understanding the magnitude and predictors of use. International journal of clinical pharmacy. 40: 580-588.
Ashur ST, Shah SA, Bosseri S & Shamsuddin K 2017. Use of traditional medicine among type 2 diabetic Libyans. Eastern Mediterranean Health Journal. 23 (5).
Association AD 2013. Standards of medical care in diabetes—2013. Diabetes care. 36 (Suppl 1): S11.
Awad A, Al-Rabiy S & Abahussain E 2008. Self-medication practices among diabetic patients in Kuwait. Medical principles and practice. 17 (4): 315-320.
Aydin S, et al. 2008. What influences herbal medicine use?-prevalence and related factors. Turkish journal of medical sciences. 38 (5): 455-463.
Azaizeh H, Fulder S, Khalil K & Said O 2003. Ethnobotanical knowledge of local Arab practitioners in the Middle Eastern region. Fitoterapia. 74 (1-2): 98-108.
Azizi-Fini I, Adib-Hajbaghery M & Gharehboghlou Z 2016. Herbal medicine use among patients with type 2 diabetes in Kashan, Iran, 2015. European journal of integrative medicine. 8 (4): 570-575.
Baldé N, et al. 2006. Herbal medicine and treatment of diabetes in Africa: an example from Guinea. Diabetes & metabolism. 32 (2): 171-175.
Boufous H, Marhoume F, Chait A & Bagri A 2017. Ethnopharmacological survey of medicinal plants with hallucinogenic effect and used against pain, inflammatory diseases, diabetes and urinary lithiasis in Zagora “Morocco”. Journal of intercultural ethnopharmacology. 6: 342-350.
Ching SM, Zakaria ZA, Paimin F & Jalalian M 2013. Complementary alternative medicine use among patients with type 2 diabetes mellitus in the primary care setting: a cross-sectional study in Malaysia. BMC complementary and alternative medicine. 13 (1): 1-7.
Da-Yong L & Ting-Ren L 2019. Herbal medicine in new era. Hospice & palliative medicine international journal. 3 (4): 125-130.
Eddouks M, Maghrani M, Lemhadri A, Ouahidi M-L & Jouad H 2002. Ethnopharmacological survey of medicinal plants used for the treatment of diabetes mellitus, hypertension and cardiac diseases in the south-east region of Morocco (Tafilalet). Journal of ethnopharmacology. 82 (2-3): 97-103.
El-Dahiyat F, Rashrash M, Abuhamdah S, Abu Farha R & Babar Z-U-D 2020. Herbal medicines: a cross-sectional study to evaluate the prevalence and predictors of use among Jordanian adults. Journal of pharmaceutical policy and practice. 13 (1): 1-9.
Ernst E 2005. The efficacy of herbal medicine–an overview. Fundamental & clinical pharmacology. 19 (4): 405-409.
Guarrera PM 1999. Traditional antihelmintic, antiparasitic and repellent uses of plants in Central Italy. Journal of ethnopharmacology. 68 (1-3): 183-192.
Hashempur MH, Heydari M, Mosavat SH, Heydari ST & Shams M 2015. Complementary and alternative medicine use in Iranian patients with diabetes mellitus. Journal of integrative medicine. 13 (5): 319-325.
Hikaambo CNa, et al. 2022. Prevalence and Patterns of Herbal Medicine Use among Type 2 Diabetes Mellitus Patients at the University Teaching Hospitals in Lusaka. Journal of biomedical research & environmental sciences. 3: 74-81.
Jafari A, Movahedzadeh D, Barsalani FR & Tehrani H 2021. Investigation of attitude, awareness, belief, and practice of complementary and alternative medicine among type 2 diabetic patients: a cross sectional study. Journal of diabetes & metabolic disorders. 20 (1): 477-484.
James PB, Wardle J, Steel A & Adams J 2018. Traditional, complementary and alternative medicine use in Sub-Saharan Africa: a systematic review. BMJ global health. 3 (5): e000895.
Jawed K, Nisar N, Hussain M & Nawab F 2019. A study based on use of Complementary and Alternative Medicine among Diabetic Patients in Karachi, Pakistan. Journal of the Dow University of Health Sciences. 13 (1).
Jouad H, Haloui M, Rhiouani H, El Hilaly J & Eddouks M 2001. Ethnobotanical survey of medicinal plants used for the treatment of diabetes, cardiac and renal diseases in the North centre region of Morocco (Fez–Boulemane). Journal of ethnopharmacology. 77 (2-3): 175-182.
Kamel FO, Magadmi RM, Hagras MM, Magadmi B & AlAhmad RA 2017. Knowledge, attitude, and beliefs toward traditional herbal medicine use among diabetics in Jeddah Saudi Arabia. Complementary therapies in clinical practice. 29: 207-212.
Khalaf AJ & Whitford DL 2010. The use of complementary and alternative medicine by patients with diabetes mellitus in Bahrain: a cross-sectional study. BMC complementary and alternative medicine. 10 (1): 35.
Khalil SH, et al. 2013. Pattern of use of complementary and alternative medicine among type 2 diabetes mellitus patients in Alexandria, Egypt. Journal of The Egyptian Public Health Association. 88 (3): 137-142.
Khuttar AH & Jallab HR 2020. Knowledge perspective and use of unconventional complementary and alternative therapy among diabetes patients attend diabetic center in Aldiwanyia teaching hospital. International journal of pharmaceutical research. 12 (4).
Lu Z, Zhong Y, Liu W, Xiang L & Deng Y 2019. The efficacy and mechanism of Chinese herbal medicine on diabetic kidney disease. Journal of diabetes research. 2019.
Mirahmadizadeh A, et al. 2020. The prevalence of undiagnosed type 2 diabetes and prediabetes in Eastern Mediterranean region (EMRO): a systematic review and meta-analysis. Diabetes research and clinical practice. 160: 107931.
Moher D, et al. 2015. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic reviews. 4 (1): 1-9.
Mozaffari-Khosravi H, Jalali-Khanabadi B-A, Afkhami-Ardekani M & Fatehi F 2009. Effects of sour tea (Hibiscus sabdariffa) on lipid profile and lipoproteins in patients with type II diabetes. Journal of alternative and complementary medicine. 15 (8): 899-903.
Naja F, et al. 2014. Prevalence and correlates of complementary and alternative medicine use among diabetic patients in Beirut, Lebanon: a cross-sectional study. BMC complementary and alternative medicine. 14 (1): 1-11.
Nentwich MM & Ulbig MW 2015. Diabetic retinopathy-ocular complications of diabetes mellitus. World journal of diabetes. 6 (3): 489.
Ondicho J, Ochora J, Matu E & Mutai J 2016. Factors associated with use of herbal medicine among patients in herbal clinics in Gucha district, Kenya. In Scientific Conference Proceedings.
Othman RB, et al. 2013. Use of hypoglycemic plants by Tunisian diabetic patients. Alexandria journal of medicine. 49 (3): 261-264.
Otoom SA, Al-Safi SA, Kerem ZK & Alkofahi A 2006. The Use of Medicinal Herbs by Diabetic Jordanian Patients. Journal of herbal pharmacotherapy. 6 (2): 31-41.
Özkum D, Akı Ö & Toklu HZ 2013. Herbal medicine use among diabetes mellitus patients in Northern Cyprus. Journal of medicinal plants research. 7 (22): 1652-1664.
Poretsky L 2010. Principles of diabetes mellitus. Springer.
Radwan H, et al. 2020. Complementary and alternative medicine use among patients with type 2 diabetes living in the United Arab Emirates. BMC Complementary medicine and therapies. 20 (1): 216.
Sabery M, Adib-Hajbaghery M & Rafiee S 2019. Satisfaction with and factors related to medicinal herb consumption in older Iranian adults. European journal of integrative medicine. 25: 100-105.
Saeedi P, et al. 2019. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas. Diabetes research and clinical practice. 157: 107843.
Salih N & Al-Asadi JN 2012. Herbal remedies use among diabetic patients in Nassyria, Iraq. World family medicine journal. 99 (316): 1-7.
Sheikhrabori A, Dehghan M, Ghaedi F & Khademi GR 2017. Complementary and Alternative Medicine Usage and Its Determinant Factors Among Diabetic Patients: An Iranian Case. Journal of evidence-based complementary and alternative medicine. 22 (3): 449-454.
Singla S 2022. Diabetes mellitus: Etiology, prevalence and effects on quality of life of diabetic patients. Published online.
Skalli S, Hassikou R & Arahou M 2019. An ethnobotanical survey of medicinal plants used for diabetes treatment in Rabat, Morocco. Heliyon. 5 (3): e01421.
Talaei B, Asghari G, Mirmiran P, Azizi F & Bahreini S 2019. Knowledge, Attitude, and Practice of Diabetic Patients toward Herbal Products in Iran: A Cross-sectional Study. Journal of nutrition and food security. 4 (3): 161-169.
Wazaify M, Afifi FU, El-Khateeb M & Ajlouni K 2011. Complementary and alternative medicine use among Jordanian patients with diabetes. Complementary therapies in clinical practice. 17 (2): 71-75.
Wazaify M, Alawwa I, Yasein N, Al-Saleh A & Afifi FU 2013. Complementary and alternative medicine (CAM) use among Jordanian patients with chronic diseases. Complementary therapies in clinical practice. 19 (3): 153-157.
World Health Organization 2006. Prevention of blindness from diabetes mellitus: report of a WHO consultation in Geneva, Switzerland, 9-11 November 2005. World Health Organization.
Yousofpour M, Kashi Z, Ahmadi Sani N, Taghavi-Shirazi M & Hashem-Dabaghian F 2016. Attitude and practice of diabetic patients towards Complementary/alternative medicine and related factors, Sari, 2014-2015. Journal of Mazandaran University of Medical Sciences. 26 (136): 135-145.


 
Type of article: review article | Subject: public specific
Received: 2022/12/26 | Published: 2024/02/21 | ePublished: 2024/02/21
References
1. Adib-Hajbaghery M, Ardakani MF, Sotoudeh A & Asadian A 2021. Prevalence of complementary and alternative medicine (CAM) among diabetic patients in Eastern Mediterranean country members of the World Health Organization (WHO): A review. Journal of herbal medicine. 29: 100476.
2. Al-Asadi JN & Salih N 2012. Herbal remedies use among diabetic patients in Nassyria, Iraq. Middle East journal of family medicine. 10: 40-46.
3. Al-Eidi S, et al. 2016. Knowledge, attitude and practice of patients with type 2 diabetes mellitus towards complementary and alternative medicine. Journal of integrative medicine. 14 (3): 187-196.
4. Al-Garni A, Al-Raddadi R & Al-Amri T 2017. Patterns and determinants of complementary and alternative medicine use among type 2 diabetic patients in a diabetic center in Saudi Arabia: herbal alternative use in type 2 diabetes. Journal of fundamental and applied sciences. 9: 1738-1748.
5. Al-Kindi RM, Al-Mushrafi M, Al-Rabaani M & Al-Zakwani I 2011. Complementary and alternative medicine use among adults with diabetes in Muscat region, Oman. Sultan Qaboos University Medical Journal. 11 (1): 62.
6. Al-Rowais NA 2002a. Herbal medicine in the treatment of diabetes mellitus. Saudi medical journal. 23 (11): 1327-1331.
7. Al-Rowais NA 2002b. Herbal medicine in the treatment of diabetes mellitus. Saudi medical journal. 23 (11): 1327-1331.
8. Al Saeedi M, El Zubier A, Bahnassi A & Al Dawood K 2003. Patterns of belief and use of traditional remedies by diabetic patients in Mecca, Saudi Arabia. Eastern Mediterranean health journal. 9 ((1-2)): 99-107.
9. Alami Z, Aynaou H, Alami B, Hdidou Y & Latrech H 2015. Herbal medicines use among diabetic patients in Oriental Morocco. Journal of pharmacognosy and phytotherapy. 7 (2): 9-17.
10. Algothamy AS, et al. 2014. Prevalence of using herbal drugs as anti-diabetic agents in Taif Area, Kingdom of Saudi Arabia. Saudi journal for health sciences. 3 (3): 137-140.
11. Ali-Shtayeh MS, Jamous RM & Jamous RM 2012. Complementary and alternative medicine use amongst Palestinian diabetic patients. Complementary therapies in clinical practice. 18 (1): 16-21.
12. Ali BAM & Mahfouz MS 2014. Herbal medicine use among patients with type 2 diabetes in North Sudan. Annual research & review in biology. 19: 1827-1838.
13. Alqathama A, et al. 2020. Herbal medicine from the perspective of type II diabetic patients and physicians: what is the relationship? BMC complementary medicine and therapies. 20 (1): 1-9.
14. Alsanad S, Aboushanab T, Khalil M & Alkhamees OA 2018. A Descriptive Review of the Prevalence and Usage of Traditional and Complementary Medicine among Saudi Diabetic Patients. Scientifica.
15. Alsanad SM 2020. Usage Assessment of Complementary and Alternative Medicine in Saudi Diabetic Patients. International journal of pharmaceutical sciences and research. 11 (4): 1941-1948.
16. Amaeze OU, et al. 2018. Herbal medicine use among type 2 diabetes mellitus patients in Nigeria: understanding the magnitude and predictors of use. International journal of clinical pharmacy. 40: 580-588.
17. Ashur ST, Shah SA, Bosseri S & Shamsuddin K 2017. Use of traditional medicine among type 2 diabetic Libyans. Eastern Mediterranean Health Journal. 23 (5).
18. Association AD 2013. Standards of medical care in diabetes—2013. Diabetes care. 36 (Suppl 1): S11.
19. Awad A, Al-Rabiy S & Abahussain E 2008. Self-medication practices among diabetic patients in Kuwait. Medical principles and practice. 17 (4): 315-320.
20. Aydin S, et al. 2008. What influences herbal medicine use?-prevalence and related factors. Turkish journal of medical sciences. 38 (5): 455-463.
21. Azaizeh H, Fulder S, Khalil K & Said O 2003. Ethnobotanical knowledge of local Arab practitioners in the Middle Eastern region. Fitoterapia. 74 (1-2): 98-108.
22. Azizi-Fini I, Adib-Hajbaghery M & Gharehboghlou Z 2016. Herbal medicine use among patients with type 2 diabetes in Kashan, Iran, 2015. European journal of integrative medicine. 8 (4): 570-575.
23. Baldé N, et al. 2006. Herbal medicine and treatment of diabetes in Africa: an example from Guinea. Diabetes & metabolism. 32 (2): 171-175.
24. Boufous H, Marhoume F, Chait A & Bagri A 2017. Ethnopharmacological survey of medicinal plants with hallucinogenic effect and used against pain, inflammatory diseases, diabetes and urinary lithiasis in Zagora “Morocco”. Journal of intercultural ethnopharmacology. 6: 342-350.
25. Ching SM, Zakaria ZA, Paimin F & Jalalian M 2013. Complementary alternative medicine use among patients with type 2 diabetes mellitus in the primary care setting: a cross-sectional study in Malaysia. BMC complementary and alternative medicine. 13 (1): 1-7.
26. Da-Yong L & Ting-Ren L 2019. Herbal medicine in new era. Hospice & palliative medicine international journal. 3 (4): 125-130.
27. Eddouks M, Maghrani M, Lemhadri A, Ouahidi M-L & Jouad H 2002. Ethnopharmacological survey of medicinal plants used for the treatment of diabetes mellitus, hypertension and cardiac diseases in the south-east region of Morocco (Tafilalet). Journal of ethnopharmacology. 82 (2-3): 97-103.
28. El-Dahiyat F, Rashrash M, Abuhamdah S, Abu Farha R & Babar Z-U-D 2020. Herbal medicines: a cross-sectional study to evaluate the prevalence and predictors of use among Jordanian adults. Journal of pharmaceutical policy and practice. 13 (1): 1-9.
29. Ernst E 2005. The efficacy of herbal medicine–an overview. Fundamental & clinical pharmacology. 19 (4): 405-409.
30. Guarrera PM 1999. Traditional antihelmintic, antiparasitic and repellent uses of plants in Central Italy. Journal of ethnopharmacology. 68 (1-3): 183-192.
31. Hashempur MH, Heydari M, Mosavat SH, Heydari ST & Shams M 2015. Complementary and alternative medicine use in Iranian patients with diabetes mellitus. Journal of integrative medicine. 13 (5): 319-325.
32. Hikaambo CNa, et al. 2022. Prevalence and Patterns of Herbal Medicine Use among Type 2 Diabetes Mellitus Patients at the University Teaching Hospitals in Lusaka. Journal of biomedical research & environmental sciences. 3: 74-81.
33. Jafari A, Movahedzadeh D, Barsalani FR & Tehrani H 2021. Investigation of attitude, awareness, belief, and practice of complementary and alternative medicine among type 2 diabetic patients: a cross sectional study. Journal of diabetes & metabolic disorders. 20 (1): 477-484.
34. James PB, Wardle J, Steel A & Adams J 2018. Traditional, complementary and alternative medicine use in Sub-Saharan Africa: a systematic review. BMJ global health. 3 (5): e000895.
35. Jawed K, Nisar N, Hussain M & Nawab F 2019. A study based on use of Complementary and Alternative Medicine among Diabetic Patients in Karachi, Pakistan. Journal of the Dow University of Health Sciences. 13 (1).
36. Jouad H, Haloui M, Rhiouani H, El Hilaly J & Eddouks M 2001. Ethnobotanical survey of medicinal plants used for the treatment of diabetes, cardiac and renal diseases in the North centre region of Morocco (Fez–Boulemane). Journal of ethnopharmacology. 77 (2-3): 175-182.
37. Kamel FO, Magadmi RM, Hagras MM, Magadmi B & AlAhmad RA 2017. Knowledge, attitude, and beliefs toward traditional herbal medicine use among diabetics in Jeddah Saudi Arabia. Complementary therapies in clinical practice. 29: 207-212.
38. Khalaf AJ & Whitford DL 2010. The use of complementary and alternative medicine by patients with diabetes mellitus in Bahrain: a cross-sectional study. BMC complementary and alternative medicine. 10 (1): 35.
39. Khalil SH, et al. 2013. Pattern of use of complementary and alternative medicine among type 2 diabetes mellitus patients in Alexandria, Egypt. Journal of The Egyptian Public Health Association. 88 (3): 137-142.
40. Khuttar AH & Jallab HR 2020. Knowledge perspective and use of unconventional complementary and alternative therapy among diabetes patients attend diabetic center in Aldiwanyia teaching hospital. International journal of pharmaceutical research. 12 (4).
41. Lu Z, Zhong Y, Liu W, Xiang L & Deng Y 2019. The efficacy and mechanism of Chinese herbal medicine on diabetic kidney disease. Journal of diabetes research. 2019.
42. Mirahmadizadeh A, et al. 2020. The prevalence of undiagnosed type 2 diabetes and prediabetes in Eastern Mediterranean region (EMRO): a systematic review and meta-analysis. Diabetes research and clinical practice. 160: 107931.
43. Moher D, et al. 2015. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic reviews. 4 (1): 1-9.
44. Mozaffari-Khosravi H, Jalali-Khanabadi B-A, Afkhami-Ardekani M & Fatehi F 2009. Effects of sour tea (Hibiscus sabdariffa) on lipid profile and lipoproteins in patients with type II diabetes. Journal of alternative and complementary medicine. 15 (8): 899-903.
45. Naja F, et al. 2014. Prevalence and correlates of complementary and alternative medicine use among diabetic patients in Beirut, Lebanon: a cross-sectional study. BMC complementary and alternative medicine. 14 (1): 1-11.
46. Nentwich MM & Ulbig MW 2015. Diabetic retinopathy-ocular complications of diabetes mellitus. World journal of diabetes. 6 (3): 489.
47. Ondicho J, Ochora J, Matu E & Mutai J 2016. Factors associated with use of herbal medicine among patients in herbal clinics in Gucha district, Kenya. In Scientific Conference Proceedings.
48. Othman RB, et al. 2013. Use of hypoglycemic plants by Tunisian diabetic patients. Alexandria journal of medicine. 49 (3): 261-264.
49. Otoom SA, Al-Safi SA, Kerem ZK & Alkofahi A 2006. The Use of Medicinal Herbs by Diabetic Jordanian Patients. Journal of herbal pharmacotherapy. 6 (2): 31-41.
50. Özkum D, Akı Ö & Toklu HZ 2013. Herbal medicine use among diabetes mellitus patients in Northern Cyprus. Journal of medicinal plants research. 7 (22): 1652-1664.
51. Poretsky L 2010. Principles of diabetes mellitus. Springer.
52. Radwan H, et al. 2020. Complementary and alternative medicine use among patients with type 2 diabetes living in the United Arab Emirates. BMC Complementary medicine and therapies. 20 (1): 216.
53. Sabery M, Adib-Hajbaghery M & Rafiee S 2019. Satisfaction with and factors related to medicinal herb consumption in older Iranian adults. European journal of integrative medicine. 25: 100-105.
54. Saeedi P, et al. 2019. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas. Diabetes research and clinical practice. 157: 107843.
55. Salih N & Al-Asadi JN 2012. Herbal remedies use among diabetic patients in Nassyria, Iraq. World family medicine journal. 99 (316): 1-7.
56. Sheikhrabori A, Dehghan M, Ghaedi F & Khademi GR 2017. Complementary and Alternative Medicine Usage and Its Determinant Factors Among Diabetic Patients: An Iranian Case. Journal of evidence-based complementary and alternative medicine. 22 (3): 449-454.
57. Singla S 2022. Diabetes mellitus: Etiology, prevalence and effects on quality of life of diabetic patients. Published online.
58. Skalli S, Hassikou R & Arahou M 2019. An ethnobotanical survey of medicinal plants used for diabetes treatment in Rabat, Morocco. Heliyon. 5 (3): e01421.
59. Talaei B, Asghari G, Mirmiran P, Azizi F & Bahreini S 2019. Knowledge, Attitude, and Practice of Diabetic Patients toward Herbal Products in Iran: A Cross-sectional Study. Journal of nutrition and food security. 4 (3): 161-169.
60. Wazaify M, Afifi FU, El-Khateeb M & Ajlouni K 2011. Complementary and alternative medicine use among Jordanian patients with diabetes. Complementary therapies in clinical practice. 17 (2): 71-75.
61. Wazaify M, Alawwa I, Yasein N, Al-Saleh A & Afifi FU 2013. Complementary and alternative medicine (CAM) use among Jordanian patients with chronic diseases. Complementary therapies in clinical practice. 19 (3): 153-157.
62. World Health Organization 2006. Prevention of blindness from diabetes mellitus: report of a WHO consultation in Geneva, Switzerland, 9-11 November 2005. World Health Organization.
63. Yousofpour M, Kashi Z, Ahmadi Sani N, Taghavi-Shirazi M & Hashem-Dabaghian F 2016. Attitude and practice of diabetic patients towards Complementary/alternative medicine and related factors, Sari, 2014-2015. Journal of Mazandaran University of Medical Sciences. 26 (136): 135-145.
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