Complementary and alternative medicine (CAM) can be used for weight loss and glycemic control. Alternative medicine comprises several systematic medical practices based on models of health and disease that differ from the medical physiology that underpins Western allopathic medicine (Table 30-1). One of the oldest practices within this rubric is traditional Chinese medicine (TCM), a system that defines health as a harmonious balance of the essential life force known as Qi (pronounced “Chee”). TCM also includes acupuncture and is used to promote wellness and to treat disease by regulating the flow of Qi along meridians that course through the body.
Acupuncture Anthroposophy Biofeedback Chiropractic Color therapy Diet fads Eclecticism Electric stimulation Homeopathy Kinesiology Massage Medicine, traditional Mental healing Moxibustion Music therapy Naturopathy Organotherapy Radiesthesia Rejuvenation Relaxation techniques Therapeutic touch |
Mind-body medical systems view health as a balance of conscious and unconscious influences of mind on bodily functions. Mind-body medicine include manipulative and body-based systems like chiropractic, osteopathy, and massage, which are said to rebalance or realign the body through manipulation. Meditation, hypnosis, music, and prayer fall under this aegis. Mind-body medicine also includes energy-modulating modalities, such as therapeutic touch, Qi Gong, and magnets, which supposedly reorder bioelectric fields in or around the body to promote wellness and healing.
The most commonly used CAM practices are biologic-based therapies, such as botanical medicine, dietary supplements, vitamins, minerals, and orthomolecular medicine. Use of botanicals has been increasing steadily over the past 40 years. The reasons are manifold. Botanicals, despite a lack of evidence, are perceived as safer than conventional pharmaceuticals. They are promoted and perceived as supporting wellness, rather than treating disease. Any person can walk into any health food store, purchase whatever products they like without consulting a health care provider, thereby exercising a high degree of control and autonomy over their health care. CAM treatments harmonize with the philosophical and ethical values of many people. They offer natural alternatives that are unprocessed and unrefined. Many consumers are impressed by the seemingly vast traditional and historical record supporting the use of CAM products, despite the fact that the record is limited to observation, anecdote, and testimonials.
Nonetheless, the rate of use of CAM continues to escalate. In the data collected during the first National Health and Nutrition Examination Survey (NHANES) in 1971–1974, 22% of adults under 50 and 27% of those over 27 used dietary supplements. By NHANES 2003–2006, rates reached 45% and 67%, respectively.
Weight loss is reportedly one of the top 20 reasons people take dietary supplements.1 Research suggests that 15% of US adults have used a weight loss dietary supplement at some point in their lives, with higher rates of use in women reporting (20.6%) than in men (9.7%).2 In the weight loss marketplace, 85% of clients for products, programs, and services are women.
Women (and men) with metabolic syndrome (metS) and other obesity-related health issues are likely to use botanicals and supplements promoted for appetite suppression, weight loss, glycemic control, metabolic stimulation, and cholesterol lowering. The offerings are vast. The products discussed next are arranged alphabetically; this list is by no means exhaustive. It is merely an attempt to highlight products, and some representative clinical trials when available, that may help clinicians, who are likely to be asked about them in the course of counseling patients with metS. A detailed review of many products can be found in an Internet textbook by Evans and Bahng.3 While it focuses on botanicals and supplements for diabetes, many of the products promoted for weight loss are covered in detail. Also, see the National Institutes of Health provides a Fact Sheet for Health Professionals reviewing weight loss supplementswebsite.4 Excellent patient educational materials are also available at the institute’s website. Also see a 2015 article by Ríos et al. on natural products for the treatment of type 2 diabetes mellitus (T2DM).5
α-Lipoic acid, also called thioctic acid (not to be confused with α-linolinic acid, also designated as ALA) is marketed primarily as a “weight loss” and “energy” supplement and as an antioxidant. It is reported to improve insulin sensitivity after both intravenous and oral therapy. One recent study included 12 patients with T2DM (mean ± SD; age 52.9 ± 9.9 years; body mass index 33.9 ± 7.4 kg/m2) for treatment with oral α-lipoic acid, 600 mg twice daily for 4 weeks. Twelve subjects with normal glucose tolerance served as a control. Using a euglycemic clamp technique, both glucose disposal rate (M) and insulin sensitivity index increased. In fact, the insulin sensitivity index in patients with T2DM did not differ statistically from the index in normal controls at the end of the treatment period. CAM practitioners typically recommend α-lipoic acid 600–1200 mg/d in tablet form. Food sources for α-lipoic acid include liver, spinach, broccoli, brussels sprouts, peas, potatoes, and yeast.
Agaricus blazei Murill (ABM) is a mushroom native to Brazil, also known as the royal sun mushroom or cogumelo do sol in Brazil or himematsutake in Japan. Extracts are marketed seemingly as a panacea for everything: cancer, T2DM, high cholesterol, arteriosclerosis, liver disease, and hematologic and gastrointestinal disorders. It is said to boost immunity and act as an adaptogen, an agent that helps with physical and psychological stress. In Japan, extracts are approved and sold as food additives. The mushroom is eaten and brewed as a tea. It is supposed to enhance insulin secretion from islets.
It does in fact improve the viability and proliferation of islets in diabetic and normal rats. A clinical randomized, double-blind, placebo-controlled trial enrolled 72 subjects with T2DM taking gliclazide and metformin for more than 6 months. The enrolled patients were randomly assigned to receive either a supplement of ABM extract or a placebo (cellulose) 1500 mg daily for 12 weeks. The homeostasis model assessment for insulin resistance (HOMA-IR) was the principle outcome measurement. At the end of the study, subjects who received the supplement of ABM extract (n = 29) showed a significantly lower HOMA-IR index (3.6 [SD 2.5] vs. 6.6 [SD 7.4], p = .04) than the control group (n = 31). The plasma adiponectin concentration increased 20% in the ABM group, while decreasing 12% in the placebo arm (p < .001).6
Kitchen or garden variety garlic (Allium sativum) is promoted for dyslipidemia. In clinical trials, garlic supplementation yielded modest reduction in total cholesterol with no significant changes in low-density lipoprotein (LDL) or high-density lipoprotein (HDL) cholesterol levels. A meta-analysis of 13 trials found that garlic reduced the total cholesterol level significantly more than a placebo, with a weighted mean decline of –15.7 mg/dL (confidence interval [CI] –25.6 to –5. 7 mg/dL). While these data suggest that garlic is superior to placebo, the effect size was modest and far from robust. The authors concluded that garlic is probably of questionable value.7 There is limited evidence that garlic lowers blood sugar in patients with T2DM.
Aloe vera is a cactus-like desert plant and is the source of a gel used for a number of dermatological conditions. In the Arabian peninsula, parts of the aloe plant are used in traditional folk medicine for diabetes, said to stimulation β-cell function.
A recent study tested aloe vera gel complex (Aloe QDM complex) in people with prediabetes or early diabetes mellitus. Participants (n = 136) were randomly assigned to interventional or control groups and evaluated at baseline and at 4 and 8 weeks. While trending down, body fat and weight, blood sugar, insulin level (p = .04), and HOMA-IR (p = .047) were not statistically significant at 8 weeks. As is common in such studies, these marginal outcomes were reported as positive findings, reminding readers to go back to the primary sources when evaluating the literature.8 Aloe vera has been linked to severe diarrhea, electrolyte abnormalities, and hepatotoxicity.
Bitter orange is the common name for Citrus aurantium. This plant is a source of synephrine alkaloids, which mimic the action of epinephrine and norepinephrine. Whether bitter orange and synephrine impose cardiovascular and central nervous system risks like those seen with epinephrine and norepinephrine is unknown. Bitter orange is supposed to exert two effects: increased energy expenditure and appetite suppression.
When ephedra was banned in 2004 by the Food and Drug Administration (FDA),9 botanical manufacturers substituted bitter orange in their weight loss formulations.
According to a review by Stohs et al.,10 23 small clinical trials used bitter orange, with a total enrollment of 360 subjects. In most, bitter orange was used in combination with caffeine and other supplements. Of the subjects, 44% consumed a bitter orange/p-synephrine-only product. The published literature noted small or no increase in heart rate or blood pressure, and there was no alteration in electrocardiograms, serum chemistry, blood cell counts, or urinalysis. p-Synephrine alone as well as in combination appeared to increase resting metabolic rate and energy expenditure and provided modest increases in weight loss at 6 to 12 weeks. The authors concluded that the evidence of efficacy and safety is far from robust.
Caffeine is almost in its own dietary class, which would include caffeine-containing herbs such as guarana (Paullinia cupana), kola or cola nut (Cola nitida), yerba mate (Ilex paraguariensis) and green tea (Camellia sinensis). Most often consumed in coffee and teas, caffeine is also added to weight loss supplements, frequently without being listed on the product label.
Caffeine is a methylxanthine and stimulates the central nervous system, heart, and skeletal muscles. It is estimated 100 mg of caffeine increases energy expenditure by approximately 9.2 kcal/h. Most clinical trials of caffeine have employed combination agents. In long-term observational studies, caffeine consumption was associated with a slight restriction in weight gain over time. Of the 18,417 men and 39,740 women enrolled in either the Health Professionals Follow-Up Study or Nurses’ Health Study, men who increased their caffeine intake during the 12 years of observation gained 0.43 kg less than those who decreased their consumption, and women gained 0.35 kg less.
In 2014, Gurley et al.11 published a detailed review of caffeine-containing supplements. They identified only 5 placebo-controlled studies that lasted more than 8 weeks using ephedra-free formulations. All the trials used multibotanicals with bitter orange and an ephedra substitute. Compared to placebo, these products led to 0 to 3.1 kg greater weight loss than that seen with placebo.
The FDA has advised limiting caffeine intake to 400 mg/d to avoid significant adverse effects.12
| Coffee, 8 oz (237 mL) | 95–200 mga |
| Coffee, 8 oz decaffeinated | 2–12 mg |
| Espresso, 1 oz (30 mL) | 47–75 mg |
| Espresso, decaffeinated, 1 oz. | 0–15 mg |
| Black tea, 8 oz (237 mL) | 14–70 mg |
| Black tea, decaffeinated, 8 oz | 0–12 mg |
| Green tea, 8 oz (237 mL) | 24–45 mg |
Cinnamon is used as a spice and is made from the inner bark of trees in the genus Cinnamomum. Cinnamon has an extensive history in folk medicine regarding its use for gastrointestinal disorders, respiratory problems, and diabetes. More recently, it has been promoted for glucose control, weight loss, and lipid disorders.
There is a distinct species difference between types of cinnamon sold. True cinnamon includes Ceylon cinnamon, Cinnamomum zeylanicum, and Cinnamomum verum. Of commercial cinnamon, 90% is a closely related species, Cinnamomum burmannii, also known as Indonesian cinnamon, Indonesian cassia, or Java cinnamon, and is designated as cassia in common labeling. This distinction between true cinnamon and cassia is not trivial. One teaspoon of cassia-type cinnamon contains 5–12 mg coumarin. The European Food Safety Authority has recommended no more than 0.1 mg coumarin intake from food daily per 2.2 pounds (1 kg) of body weight. For the generic 70-kg man, the upper limit of intake is 7 mg of coumarin. Therefore, dietary intake of cassia should be limited to 1 teaspoon per day for the average person. Ceylon cinnamon, true cinnamon, contains only traces of coumarin.13 But, it is the high-coumarin cassia that is said to improve glucose tolerance.
The Cochrane Collaborative reviewed cinnamon in 2012 and identified 10 prospective, randomized controlled trials (RCTs), with 577 participants with types 1 and 2 diabetes mellitus. Eight studies were judged to be at high or unclear risk of bias, and the remaining 2 at moderate risk. Most studies used cinnamon cassia with a mean dose of 2 g daily for 4 to 16 weeks. The impact on glucose was inconclusive. There was no discernible effect on glycosylated hemoglobin A1c (HbA1c), serum insulin, or postprandial glucose. None of the trials reported health-related quality of life, morbidity, mortality, or costs.14
A more recent review and meta-analysis of cinnamon, glucose, and lipid levels was published in 2013. In patients with T2DM, 10 RCTs with 543 patients were included. Cinnamon doses between 120 mg/d and 6 g/d for 4 to 18 weeks lowered fasting plasma glucose by –24.59 mg/dL (95% CI –40.52 to –8.67 mg/dL); total cholesterol –15.60 mg/dL (95% CI, –29.76 to –1.44 mg/dL); LDL cholesterol (LDL-C) –9.42 mg/dL (95% CI –17.21 to –1.63 mg/dL); and triglycerides –29.59 mg/dL (95% CI –48.27 to –10.91 mg/dL); they also raised HDL cholesterol (HDL-C) 1.66 mg/dL (95% CI 1.09 to 2.24 mg/dL). No significant change in HbA1c was noted.15
Due to a lack of sufficient evidence, neither the National Center for Complementary and Alternative Medicine (NCCAM) nor the American Diabetes Association recommends the use of cinnamon supplementation. Nonetheless, owing to minimal safety concerns around cinnamon, CAM practitioners continue to recommend its use, often in large doses.
Chitosan is a polysaccharide extracted from the exoskeletons of crustaceans. It supposedly absorbs fat, reducing its nutritional and caloric impact. The fat trapped, however, appears to be clinically insignificant.16 In a Cochrane Collaborative review of 13 trials, chitosan (when taken for 4 weeks to 6 months) reduced body weight by a mean of 1.7 kg compared with placebo. The authors noted that the trials were poor quality, and that in the well-designed studies, chitosan was minimally effective.17
Chromium, after calcium, is the most commonly purchased mineral supplement in the United States. The most commonly sold form is chromium picolinate, although CAM dietary experts assert that trivalent chromium is the most effective form for glucose intolerance. It is promoted for diabetes, obesity, metS, and T2DM.
The mechanism of action suggested is enhanced insulin binding, insulin receptor number, insulin internalization, and β-cell sensitivity. In reviewing chromium intake and effects on glucose intolerance, the FDA has said that the relationship between chromium picolinate intake and insulin resistance is highly uncertain.18 Three reviews have been published to date, the first concluding that there may be some clinical efficacy but there is insufficient documentation of long-term benefit and safety.19 In 2013, a Cochrane review analyzed 9 RCTs of chromium picolinate for weight loss; the trials included 622 overweight or obese participants. Subjects received 200–1000 μg per day for 8 weeks to 6 months. Six of the trials included resistance or weight training. Overall, chromium picolinate supplementation reduced body weight by 1.1 kg more than placebo, but weight loss had no correlation to the dose of chromium picolinate administered.20 Another review was published that same year with 11 RCTs that included 866 overweight or obese individuals. The studies used chromium picolinate 137 to 1000 μg for 8 to 26 weeks. Chromium appeared to reduce body weight by 0.5 kg and percentage body fat by 0.46% more than placebo. Similar findings were reported in an earlier meta-analysis of 12 trials.21
Coenzyme Q10 is a cofactor used in oxidative metabolism. Supplements are often recommended as an adjunct for patients taking HMG CoA (3-hydroxy-3-methylglutaryl coenzyme A) reductase inhibitors to lessen side effects thought to be due to depletion of naturally occurring coenzyme Q10 by the action of statins. The most often posited benefit of coenzyme Q10 is mitigation of statin-induced myopathy, although the available studies to date have failed to document significant benefit.22
Small studies have suggested that coenzyme Q10 might affect both T2DM and metS. In a 2015 meta-analysis, 7 trials were identified that included 356 patients. Neither coenzyme Q10 alone nor coenzyme Q10 plus fenofibrate improved glycemic control, LDL-C, HDL-C, and blood pressure, but triglycerides and total cholesterol did improve significantly. The authors noted that the studies were small, underpowered, and often poorly designed.23 In a recent trial, 64 patients with T2DM were randomly assigned to receive either 200 mg coenzyme Q10 or placebo daily for 12 weeks. Serum HbA1c concentration decreased in the group treated with coenzyme Q10.24
Coccinia indica (ivy gourd) is a creeping vine that has been used in traditional Indian Ayurvedic medicine to treat diabetes and is postulated to have insulinlike activity. In a small trial, 60 patients (aged 35–60 years) with T2DM were randomly assigned to placebo or treatment using 1 g extract of coccinia for 90 days. Fasting and postprandial blood glucose levels decreased by 16% and 18%, respectively (p < .05), and HbA1c declined 0.6%.25 Further study is needed to confirm and validate these findings.
Coconut oil is being touted as a healthy fat, said to improve the lipid profile and lower the risk for cardiovascular disease, stroke, and Alzheimer disease. It is said to also promote weight loss and lower the risk of diabetes. None of these claims have been substantiated. Coconut oil is a saturated fat containing predominantly medium-chain triglycerides, which are metabolized differently from the long-chain triglycerides found in most other oils. In a small trial, 40 obese women were told to cook with 2 tablespoons coconut oil or soybean oil each day. After 3 months, in the women given coconut oil, waist circumference dropped from 39 inches to 38.5 inches (p = .005). While reported as significant, the change is not clinically meaningful. HDL increased and LDL decreased in the coconut group.26
Forskolin is extracted from the root of the Coleus forskohlii plant, which is grown in India and Thailand. Studies are limited; in 1 small RCT, 19 overweight or obese females aged 18–40 years were given either forskolin (250 mg twice daily) or placebo while maintaining their usual diet for 12 weeks. There was no effect on weight.27 A similar study in men also found no effect.
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