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Use of medicinal plants for

diabetes in Trinidad and Tobago


D. Mahabir 1 and M. C. Gulliford 2

ABSTRACT Use of herbal remedies from medicinal plants (bush medicines) was studied in 622 people with
diabetes mellitus attending 17 government health centers on the island of Trinidad, Trinidad
and Tobago. Bush medicines were used by 42% of patients surveyed and were used for diabetes
by 24%. Bush medicine use was more frequent in Afro-Trinidadians and in those of mixed eth-
nicity than in Indo-Trinidadians, and was also more prevalent in those with lower educational
attainment. Most patients using bush medicines (214/264, or 81%) reported gathering the
plants themselves, and 107/264 (41%) took them more frequently than once a week. Patients
taking bush medicines mentioned 103 different plants used in remedies. Among the 12 most
frequently mentioned, caraili, aloes, olive-bush, and seed-under-leaf were preferentially used
for diabetes. Vervine, chandilay, soursop, fever grass, and orange peel were preferentially used
for other indications. Patients who reported burning or numbness in the feet or feelings of
tiredness, weakness, giddiness, or dizziness used bush medicines for diabetes more frequently
than did patients who reported a range of other diabetes-related symptoms. Insulin-treated
patients were less frequent users of bush medicines. It is concluded that bush medicines are
taken regularly by many patients with diabetes in Trinidad. Plants most frequently used as
remedies for diabetes have recognized hypoglycemic activity. Patients’ culture, educational
background, type of symptoms, and formal medical treatment may also influence the selection
and use of bush medicines.

Herbal remedies from medicinal tic effects (1); they may also have toxic cles to establishing effective patterns
plants (known in the Caribbean as side-effects (2); and use of bush medi- of self-care.
bush medicines) have been used tradi- cines provides an indication of beliefs Several studies from the Caribbean
tionally in regions where access to for- about illness and its treatment that region have described the plants used
mal health care is limited. There are may conflict with beliefs of workers in for medicinal purposes and have out-
several reasons why use of bush med- the formal health care system (3). lined the social history of bush medi-
icines should be studied: herbal reme- Over the last three decades chronic cine use (6–8), but there have been few
dies may have recognizable therapeu- disorders such as diabetes and hyper- epidemiologic studies of the subject.
tension have emerged as the major This report describes a study under-
causes of adult morbidity and mortal- taken to investigate bush medicine
ity in the Caribbean islands (4). Suc- use among people with diabetes in
1 Nutrition and Metabolism Division, Ministry of cessful control of health problems Trinidad and Tobago with a view to
Health, Trinidad and Tobago. stemming from diabetes and hyper- answering the following questions: (1)
2 Commonwealth Caribbean Medical Research
Council, and Division of Public Health Sciences, tension requires active participation of How prevalent is bush medicine use?
UMDS, Guy’s and St. Thomas’s Medical and patients in their own care, but as Mor- (2) What are the sources and types of
Dental Schools, London, United Kingdom. Re-
print requests and other correspondence should gan (5) has pointed out, health care remedies used? (3) What factors are
be addressed to this author at: Department of providers’ limited understanding of associated with the use of bush medi-
Public Health Medicine, St. Thomas’s Hospital,
London SE1 7EH, UK. Fax: 44-171-928-1468;
Caribbean patients’ concepts of illness cines by people with diabetes in
e-mail: m.gulliford@umds.ac.uk. and ideas about treatment are obsta- Trinidad?

174 Rev Panam Salud Publica/Pan Am J Public Health 1(3), 1997


METHODS • “Where do you get bush medi- Univariate analyses were performed
cines?” by cross-tabulation and estimation of
Subjects • “How often do you use bush medi- chi-square statistics. Multiple logistic
cines?” regression analyses were performed to
Trinidad and Tobago provides pri- • “What plants do you use for bush explore possible associations of bush
mary medical services through a net- medicines?” medicine use for diabetes with ex-
work of just over 100 health centers. planatory variables (9). A single step-
Two health centers from each of eight The last question was open-ended wise regression with backwards elimi-
administrative counties on the island and allowed for up to six responses. nation was performed to identify any
of Trinidad were randomly selected. When possible, specific plants were symptom or treatment variable inde-
One health center was replaced by the identified from standard reference pendently associated with bush medi-
outpatient clinic of a small district hos- works, particularly the studies by cine use for diabetes after adjusting for
pital nearby, because the latter was Seaforth et al. (6) and Ayensu (7). age, gender, ethnicity, and educational
known to draw its patients from a Additional data were obtained by attainment.
wide area in the more remote eastern interview concerning patients’ age,
part of the island. One health center gender, self-reported ethnic group,
had a small number of attenders with and educational attainment. For analy- RESULTS
diabetes, so another health center was sis these variables were reduced to
added to the sample from that county. the following categories: age group Interviews were completed for 627
At each health center, patients attend- (≤44; 45–54; 55–64; 65–74; ≥75 years); subjects. Two subjects with missing
ing the clinic for adults were selected gender (male, female); self-reported age information and three identified as
for the survey. In most instances, these ethnic group (Afro-Trinidadian, Indo- white or Chinese were excluded, so
subjects were attending a designated Trinidadian, mixed); and educational data were analyzed from 622 inter-
“chronic disease clinic,” but a few attainment (no schooling; primary; views. Interview data were obtained
health centers had “health office” clin- secondary or higher; not known). from 204 men and 418 women.
ics for adult attenders with any type Data on patient symptoms were Table 1 shows frequency of bush
of medical complaint. Within each obtained in response to two open- medicine use according to ethnic
health center, subjects with diabetes ended questions and several closed group. Overall, 264 out of 622 patients,
were randomly sampled by using the questions concerning specific diabetes- or 42%, reported using bush medi-
numbers they were assigned when related symptoms. In the open-ended cines. Bush medicine use was more
they queued for consultation. The aim questions, subjects were asked to frequent among Afro-Trinidadians
was to interview at least 38 patients respond to the following: “Tell me the and persons of mixed ethnicity than
from each of the 17 health centers in one problem from diabetes that trou- among Indo-Trinidadians. Among
order to achieve a total sample size of bles you most,” and “Tell me five other bush medicine users, 152/264 (58%)
at least 600. problems from diabetes that trouble reported taking bush medicines for
you.” Responses were coded into diabetes; use for diabetes tended to be
broad groups. The most frequent higher among Indo-Trinidadians
Data collection spontaneously mentioned complaints (74/119, or 62%) than among Afro-
were of foot problems, difficulty sleep- Trinidadians (52/97, or 54%), but the
Subjects were interviewed by nutri- ing, eye problems, itching, pain, thirst difference was not statistically signifi-
tionists who were staff members of the and polyuria, sex problems, tiredness, cant. Most patients reported collecting
Ministry of Health’s Nutrition Divi- weakness, giddiness, and dizziness. their own medicinal plants (214/264,
sion and who usually worked in the The last four symptoms were com- or 81%) and a few were supplied with
health center environment. The ques- bined because they seemed to repre- bush medicines by friends or relatives,
tionnaire was written in standard Eng- sent similar concepts. The closed- but little use was made of herbal
lish. Interviewers were instructed that ended questions pertained to the shops, herbalists, or bush medicine
it was acceptable to rephrase the ques- presence or absence of itching, poly- doctors. Bush medicines were used at
tions in Trinidadian vernacular but not uria, difficulty with eyesight, past his- least every week by 107/264, or 41% of
to prompt replies. The following ques- tory of foot ulceration, and burning or patients surveyed. The frequency of
tions were included concerning the numbness in the feet. bush medicine use was not clear for
use of bush medicines: Information on drug treatments 56/264 (21%) of users, possibly
being administered for diabetes was because they only took bush medi-
• “Many people in Trinidad use bush taken from clinical notes on each pa- cines when specific (and perhaps self-
medicines; do you use bush medi- tient. These treatments included insu- limiting) illnesses were experienced.
cines?” lin, sulfonylurea drugs, metformin, or The associations of bush medicine
• “Do you use bush medicines for a combination of sulfonylurea drugs use for diabetes with social and demo-
your diabetes?” and metformin. graphic characteristics are shown in

Rev Panam Salud Publica/Pan Am J Public Health 1(3), 1997 175


TABLE 1. Use of bush medicines according to ethnic group practice reflected an informal pattern
of self-care that rarely involved practi-
Afro- Indo- tioners of folk medicine. Selection of
Trinidadian Trinidadian Mixed
(n = 188) (n = 333) (n = 101)
remedies was influenced by patients’
ethnic group and educational back-
No. (%) No. (%) No. (%)
ground. The results suggested that the
Do you use bush medicines? (yes) a 97 (52) 119 (36) 48 (48) use of bush medicines is influenced by
Do you use bush medicines 52 (28) 74 (22) 26 (26)
the type of symptoms experienced by
for diabetes? (yes)a the patient and by the type of formal
treatment being received at the health
Where do you get bush medicine? b
Collect own 81 (84) 89 (75) 44 (92) centers. However, additional study
Friend or relative 6 (6) 9 (8) 2 (4) would be required to explore these
Herbal shop 2 (2) 5 (4) 0 (0) possibilities further. Use of remedies
Bush medicine doctor 0 (0) 1 (1) 0 (0) from medicinal plants has three main
Other/not known 8 (8) 15 (13) 2 (4)
implications: such plants may have
How often do you take bush medicine?b significant hypoglycemic effects; prep-
Every day 16 (17) 11 (9) 10 (21)
arations from medicinal plants may
More than once a week 30 (31) 24 (20) 16 (33)
More than once a month 18 (19) 27 (23) 9 (19) also have toxic side-effects; and pa-
Less than once a month 15 (15) 24 (20) 8 (17) tients who use bush medicines may
Not known 18 (19) 33 (28) 5 (10) modify their use of and responses to
a Percentages are of total number in that ethnic group.
formal treatments.
b Percentages are of all bush medicine users in that ethnic group. Bailey and Day (1) reviewed the
hypoglycemic effects of medicinal
plants and divided traditional reme-
dies into three groups: those from
which a reputedly hypoglycemic com-
Table 2. There was no increase in bush tioned 103 different plants incorpo- pound had been isolated; those re-
medicine use with age, and gender dif- rated in remedies. Plants selected as ported to have a hypoglycemic effect
ferences were not significant. As indi- bush medicines included some com- but for which the nature of the active
cated above, their use for diabetes was monly consumed in food or drink, for principle was not established; and
more frequently reported by Afro- example, caraili (bitter gourd) and those reputed to exert a hypoglycemic
Trinidadians and persons of mixed mauby. Others, such as vervine, effect but for which the scientific evi-
ethnicity than by Indo-Trinidadians. chandilay, fever grass, and periwinkle, dence was equivocal. Among the
Among those with secondary educa- were more specifically recognizable as plants used by the subjects in the pres-
tion 13% reported using bush medi- medicinal plants. Table 3 lists the 12 ent survey, caraili (Momordica charan-
cines for diabetes, compared with 25% most frequently mentioned plants and tia), aloe (Aloe vera), periwinkle (Catha-
of those with primary school educa- shows their frequency of use for dia- ranthus roseus), garlic (Allium sativum),
tion and 26% of those with no school- betes or for other indications. Caraili, and ginseng (Panax ginseng) have
ing. Inclusion of health center of atten- aloes, olive-bush, and seed-under-leaf established hypoglycemic activity (1).
dance or electoral ward of residence in tended to be used preferentially for Caraili (or bitter gourd) is particularly
regression models did not identify sig- diabetes, while vervine, chandilay, important because it is a commonly
nificant geographical variation in bush soursop, fever grass, and orange peel eaten vegetable and may be consumed
medicine use within Trinidad. Signifi- tended to be employed for other indi- in significant quantities. The hypo-
cantly higher use of bush medicines cations. There were minor variations in glycemic effects of extracts of Momor-
for diabetes was found in patients who the prevalence of use of different plants dica charantia are well established, and
responded positively to the question among the ethnic groups: vervine, the plant has been reported to cause
“Do you have burning or numbness in olive-bush, and orange peel were less hypoglycemia in a patient already tak-
your feet” (P = 0.009) and by patients often used by Indo-Trinidadians. ing sulfonylurea drugs to treat dia-
who included the symptoms tiredness, betes (10–12). Absent from this list of
weakness, giddiness, or dizziness in plants is ackee (Blighia sapida), whose
their spontaneous complaints (P = DISCUSSION unripe fruits cause hypoglycemia and
0.011). Fewer patients being treated are reported to be used to treat dia-
with insulin used bush medicines than This survey showed that 22% to 28% betes in Central America (1). The ackee
patients not taking insulin. (depending on ethnic group) of pa- tree is uncommon in Trinidad.
A list of the plants used for bush tients attending government health Toxic effects of herbal remedies used
medicines is given in Appendix 1. centers for diabetes in Trinidad were for diabetes have been reported.
Overall, 264 bush medicine users men- regular users of bush medicines. This Heavy metal contamination has been

176 Mahabir and Gulliford • Medicinal plants for diabetes in Trinidad and Tobago
TABLE 2. Associations of social and demographic factors with use of bush medicine for dia- found in herbal remedies from the
betes and logistic regression analyses of data Indian subcontinent (2). Such contam-
ination seems unlikely in the Carib-
Variable Cases/totala (%) OR (95% CI) Chi-square P value
bean, where plants are usually har-
Age group (years) vested for immediate use. Hernandez
≤ 44 14/69 (20) 1.00 4.94 0.293 et al. (13), in a study of medicinal plant
45 to 54 39/143 (27) 1.20 (0.58 to 2.49) use in Puerto Rico, reviewed the evi-
55 to 64 51/191 (27) 1.05 (0.51 to 2.15)
dence that use of soursop (Annona
65 to 74 32/148 (22) 0.70 (0.32 to 1.50)
≥ 75 16/71 (23) 0.67 (0.28 to 1.62) muricata) leaf extract might carry a risk
of inducing neoplasms.
Gender
Male 46/204 (23) 1.00 0.03 0.872 This survey provides insight into
Female 106/418 (25) 0.97 (0.63 to 1.47) patterns of informal self-care in Trin-
Ethnic group
idad and Tobago. During the course of
Afro-Trinidadian 52/188 (28) 1.00 7.14 0.028 its development, the country has been
Indo-Trinidadian 74/333 (22) 0.55 (0.34 to 0.87) subject to a range of cultural influ-
Mixed 26/101 (26) 0.90 (0.51 to 1.60) ences, including those from the
Educational attainment indigenous Amerindian population,
Secondary schooling or higher 9/68 (13) 1.00 8.05 0.045 from Spanish and later English
Primary school 117/462 (25) 2.22 (1.02 to 4.80) colonists, from immigrant popula-
No school 21/82 (26) 2.68 (1.02 to 7.07)
Not known 5/10 (50) 6.74 (1.53 to 29.7)
tions from West Africa and later the
Indian subcontinent, and from contin-
Burning or numbness in feet:
No 51/272 (19) 1.00 6.91 0.009
uing interchange with Venezuela and
Yes 101/350 (29) 1.70 (1.14 to 2.55) Eastern Caribbean islands (14). Bush
medicine use was common in both of
Spontaneous complaints include
tiredness, giddiness, weakness, the main ethnic groups, suggesting
or dizziness: that utilization of medicinal plants is
No 85/407 (21) 1.00 6.40 0.011 part of a shared culture. Neverthe-
Yes 67/215 (31) 1.66 (1.12 to 2.46) less, there were also differences in the
Insulin treatment: prevalence of bush medicine use and
No 139/534 (26) 1.00 4.81 0.028 the selection of medicinal plants
Yes 13/88 (15) 0.51 (0.27 to 0.96)
among the ethnic groups. Selection of
a Users of bush medicine for diabetes/total number of survey participants in the category. medicinal plants showed some simi-
larity with patterns reported from
other Caribbean islands (7, 15). It is
also interesting to compare the selec-
TABLE 3. Comparison of use of 12 most frequently mentioned plants for diabetes or for tion of medicinal plants in Trinidad
other indications with that reported for the population
of Indian origin in Fiji (16). Several
Persons plants used in Fiji were also men-
Persons using using plant as tioned in Trinidad, including Agera-
plant as bush bush medicine,
tum conyzoides (zeb-a-fam), Momordica
medicine for but not for
diabetes (n = 152) diabetes (n = 112) charantia (caraili), Mimosa pudica
Chi- (teemarie), Allium sativum (garlic),
Plant No. (%) No. (%) square
Mangifera indica (mango), Cymbopogan
Caraili 43 (28) 12 (11) 12.08a citratus (fever grass), Tamarindus indica
Vervine 12 (8) 20 (18) 6.01b (tamarind), and Carica papaya (paw-
Aloes 23 (15) 6 (5) 6.30a paw).
Zebapique 20 (13) 7 (6) 3.35
Trinidad and Tobago is an upper-
Chandilay 7 (5) 15 (13) 6.52b
Soursop (leaf) 5 (3) 16 (14) 10.65b middle-income country in which the
Olive-bush 15 (10) 3 (3) 5.25a importance of agricultural occupa-
Fever grass 3 (2) 14 (13) 11.86b tions has declined. The population has
Senna 7 (5) 8 (7) 0.78 tended to concentrate in urban areas,
Orange peel 1 (1) 11 (10) 12.48b,c
Seed-under-leaf 10 (7) 1 (1) 5.22a
but the main towns are small and
Black sage 5 (3) 5 (5) 0.20 clear-cut distinctions between urban
a
and rural areas are difficult to make.
Significantly more used for diabetes than for other indications.
b Significantly less used for diabetes than for other indications. Consistent with this pattern, there was
c Expected value less than five. no indication of significant geographi-

Rev Panam Salud Publica/Pan Am J Public Health 1(3), 1997 177


cal variation in bush medicine use Appendix 1. List of plants that were mentioned by more than one survey participant as
within Trinidad. Bush medicines are herbal remediesa
still widely employed despite a rela-
tively advanced health care system No. of
Vernacular name Latin name mentions
that includes universal access to free
prescription of pharmaceuticals. Use Caraili Momordica charantia 55
of bush medicines is less common Vervine Stachytarpheta jamaicensis 32
among those with higher educational Aloes Aloe vera, Aloe barbadensis 29
Zebapique Neurolaena lobata 27
attainment and will no doubt continue
Chandilay, shandelier, ball bush Leonotis nepetifolia 22
to decline as external cultural influ- Soursop, soursop leaf Annona muricata 21
ences become more important. The Olive-bush Bontia daphnoides 18
survey did not find an increase in bush Fever grass, lemon grass Cymbopogan citratus 17
medicine use with age, as might have Senna, wild senna Cassia italica 15
been expected if more recent birth Orange peel Citrus sp. 12
Seed-under-leaf, button-under-leaf Phyllanthus amarus 11
cohorts were less likely to continue
Black sage Cordia curassavica 10
traditional practices. However, it is Christmas bush Eupatorium odoratum 8
possible that selection biases associ- Shining bush Peperonia pellucida 8
ated with attendance at government Carpenter grass, bush Justicia pectoralis 7
health centers influenced the different Periwinkle, old maid Catharanthus roseus 7
age groups differently. Shadow bennie, shadom bennie Eryngium foetidum 7
Water grass Sambucus simpsonii 7
This study represents one of the Celery Apium graveolens 6
larger surveys of medicinal plant use Boiscano, bacano, trumpet bush Cecropia peltata 5
in a middle-income country, but it was Detipei, datapayee, obeah bush Capraria biflora 5
not based on a population-wide sam- Ginger Zingiber officinale 5
ple. By sampling from government Mauby bark, mauby Colubrina arborescens 5
Mint [various] 5
health centers, an economically less
Sweet broom Scoparia dulcis 5
privileged group of the population Whitehead broom Parthenium hysterophorus 5
was recruited. (It should be noted that Wonder-of-world Bryophyllum pinnatum 5
private general practice may account Karikeet, caraquite Lantana camara 4
for half of primary care consultations Lime leaf, lime bud Citrus aurantifolia 4
in the country.) In addition, less fre- St. John bush Justicia secunda 4
Twef/tref/threft/treft Aristolochia trilobata 4
quent users of formal health care, Barbadine leaf Passiflora quadrangularis 3
among whom the use of informal folk Bay leaf Pimenta racemosa 3
remedies might be higher, may have Cerrio Sombusus intermedia 3
been underrepresented by this sam- Garlic Allium sativum 3
pling procedure. Medicinal plants Jigger bush Tournefortia hirsutissima 3
Kaisematio, kuze maho Urena lobata 3
were identified simply from the ver-
Molasses — 3
nacular names reported by patients, Rabbit bush — 3
and no attempt was made to collect Roucou leaves Bixa orellana 3
samples for identification. Seaforth et Zeb-a-fam Ageratum conyzoides 3
al. (6 ) have pointed out that identifica- Basilique Ocimum americanum 2
tion of species from vernacular names Bitter bush with white flower Eupatorum villosum 2
Calabash Crescentia cujete 2
is sometimes unreliable because the
Charcoal — 2
same name may be applied to different Double hibiscus, hibiscus Hibiscus rosa-sinensis 2
plants in the same or different regions. Honeysuckle Bidens reptans 2
Some of the analyses in this study Malomey Euphorbia hirta 2
were conducted in the spirit of explor- Mat root Aristolochia rugosa 2
atory data analysis without definite Needle bush, railway daisy Bidens pilosa 2
Paw-paw Carica papaya 2
prior hypotheses, and the results Tamarind leaf Tamarindus indica 2
should therefore be interpreted cau- Teemarie Mimosa pudica 2
tiously. Despite potential biases and Toosie leaf/toolsie Ocimum gratissimum 2
limitations, these results provide an Zabocca leaf, avocado leaf Persea americana 2
insight into the extent of use of medic- Gotokola — 2
Neeb leaf — 2
inal plants for herbal remedies in a
Pressure bush — 2
middle-income country with relatively
a 45
advanced health services. others each mentioned once.

178 Mahabir and Gulliford • Medicinal plants for diabetes in Trinidad and Tobago
Acknowledgments. We thank the Division for their work on the survey, paper. M.C.G. was supported by the
Chief Medical Officer of Trinidad and Dr. David Picou for his support. United Kingdom Overseas Develop-
and Tobago for permission to report We also thank Dr. M. Morgan for her ment Administration.
this study, the staff of the Nutrition comments on an earlier draft of this

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RESUMEN El uso de remedios a base de plantas medicinales (medicinas herbolarias) se


estudió en 622 personas con diabetes mellitus que asistían a 17 centros de salud
gubernamentales en la isla de Trinidad, en Trinidad y Tabago. Se observó el uso
Uso de plantas de medicinas herbolarias en 42% de los pacientes encuestados y su utilización
medicinales para la diabetes para la diabetes se observó en 24%. El empleo de estas medicinas fue más fre-
en Trinidad y Tabago cuente en habitantes de Trinidad de herencia africana o mixta que en los de ascen-
dencia india oriental. También fue más común en personas de baja escolaridad.
La mayoría de los pacientes que usaban medicinas herbolarias (214/264, u 81%)
dijeron que ellos mismos recogían las plantas y 107/264 (41%) las consumían más
de una vez a la semana. Los pacientes que tomaban estas medicinas mencionaron
103 tipos distintos de plantas que se usaban para hacer remedios. Entre las 12
mencionadas con mayor frecuencia, Momordica charantia (“caraili”), los áloes,
Bontia daphnoides (“olive bush”) y la planta Phyllantus amarus se usaban específi-
camente para la diabetes. La verbena, la planta Leonotis nepetifolia (“chandilay”),
el guanábano, la hierba Cymbopogan citratus (“fever grass”) y la cáscara de naranja
se usaban más bien para otros problemas. Los pacientes que se quejaban de una
sensación urente o de entumecimiento en los pies, o de cansancio, debilidad, sen-
sación de desmayo o mareo usaban las medicinas herbolarias para la diabetes con
más frecuencia que los pacientes que notificaron tener otras manifestaciones de
esa enfermedad. Los pacientes tratados con insulina usaban medicamentos her-
bolarios con menos frecuencia. Se concluye que las medicinas herbolarias son
usadas con regularidad por muchos pacientes diabéticos en Trinidad. Las plantas
utilizadas con mayor frecuencia para tratar la diabetes tienen actividad hipo-
glicemiante reconocida. El fondo cultural del paciente, así como su grado de esco-
laridad, sintomatología y tratamiento médico formal, también pueden ejercer
influencia en la selección y uso de los medicamentos herbolarios.

Rev Panam Salud Publica/Pan Am J Public Health 1(3), 1997 179