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Complementary Therapies in Medicine (2015) xxx, xxx—xxx

Available online at www.sciencedirect.com

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journal homepage: www.elsevierhealth.com/journals/ctim

Complementary and alternative medicines

for diabetes mellitus management in ASEAN
countries
Ganniga Pumthong a,∗, Amornrat Nathason b,
Musikorn Tuseewan a, Pailin Pinthong b, Supathra Klangprapun a,
Daracha Thepsuriyanon a, Paiwan Kotta b

a
Faculty of Thai Traditional and Alternative Medicine, Ubonratchathani Rajabhat University, Meung,
Ubonratchathani 34000, Thailand
b
Faculty of Nursing, Ubonratchathani Rajabhat University, Meung, Ubonratchathani 34000, Thailand

Received 16 October 2013; received in revised form 3 December 2014; accepted 21 January 2015

KEYWORDS Summary
Aim: The aim of this study was to explore complementary or alternative practices used to
Qualitative research;
promote health and reduce complications of patients with diabetes mellitus (DM).
Diabetic mellitus;
Design: This qualitative, interpretative study recruited 30 adults including practitioners (n = 15)
Complementary and
and DM patients (n = 15). The participants reside in the northeast of Thailand and in Vientiane
alternative medicine;
of Lao People’s Democratic Republic, and they have undergone treatment with at least a kind
Acupuncture;
of complementary and alternative medicines (CAMs) for the care and management of DM. They
Massage;
were interviewed about their experiences, and the data were analyzed thematically. The study
Herbalism
methodology was informed by hermeneutic phenomenology.
Result: After several years of ineffective treatments, practitioners looked for an alternative to
conventional health care to treat patients on long-term antidiabetic drugs, yet the patients suf-
fered from progressive complications. They sought out health care that would more effectively
meet their self-perceived needs in treatment particularly of a chronic disease such as DM. The
result suggested that CAMs such as acupuncture, massage, exercise, and herbalism were able
to meet their requirement in terms of health-care effectiveness obtained from experiences,
additional cheap cost and availability in their community, and in accordance with the culture
and lifestyles in the context of the ASEAN (Association of Southeast Asian Nations) community.

∗ Corresponding author. Tel.: +66 045352000x4300; mobile: +66 0815473642.

E-mail address: ganniga10@hotmail.com (G. Pumthong).

http://dx.doi.org/10.1016/j.ctim.2015.01.016
0965-2299/© 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Pumthong G, et al. Complementary and alternative medicines for diabetes mellitus
management in ASEAN countries. Complement Ther Med (2015), http://dx.doi.org/10.1016/j.ctim.2015.01.016
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2 G. Pumthong et al.

Conclusion: The study explored and revealed the social perceptions of practitioners and patients
using Chinese acupuncture, Thai massage, stretching exercise, and herbalism, as CAMs for DM
management. The perceptions attributed to patient—practitioner consensus can hold a key to
a more comprehensive health care, as a means to expand the boundaries for contemporary
health-care provision. However, more study is needed in the future clinical trial research.
© 2015 Elsevier Ltd. All rights reserved.

Introduction Acupuncture originated in China about 2500 years ago,

Diabetes mellitus (DM) is a metabolic syndrome causing car-
diovascular complications, which is also a leading cause
of blindness, amputation, and kidney failure. In 2012, the
International Diabetes Federation (IDF) updated that >371
million people were diabetic. The number of people with
diabetes has been increasing in every country. Half of peo-
ple with diabetes were undiagnosed. In 2012, 4.8 million
people died due to diabetes, and >471 billion USD were
spent on health care for diabetes.1 While much of this
increase is expected to occur in developing countries, the
reasons behind the increase are not country specific but the
consequence of population aging, increasing urbanization,
unhealthy diets, obesity, and sedentary lifestyles. These
account for much of the social and financial burden of the
disease.2,3
In Thailand, the number of diabetic patients was
dramatically increased up to 5.4 million in 2012. The
number also included patients who were undiagnosed and
untreated.1 Apparently, long-term treatment with conven-
tional medicine could not help the DM patients to live
healthy and delay progressive complications. This requires
that individuals and organizations keep abreast of changing
health-care needs and continually look for ways to provide
appropriate care. The use of complementary and alterna-
tive medicines (CAMs) was offered to be the selected issue
and potential strategy toward meeting chronic disease man-
agement needs.4
‘‘CAMs’’ are defined as diverse therapeutic practices
and alternative health-care approaches that fall outside the
boundaries of conventional, allopathic medicine.5 Moreover,
CAM may include forms of treatment, diagnosis, and/or pre-
vention that complement mainstream medicine by satisfying
a demand not met by conventional approaches, or by diversi-
fying the conceptual framework of medicine.6 Chronically ill
people are reported to use CAM two to five times more often
than non-chronically ill people.7 The demand for CAM ser-
vices is expected to rise particularly as a result of population
aging and a subsequent likely increase among people who
will experience one or more chronic health problems.7—10
Diabetes care involves more than glycemic control, and
it is important to manage other cardiovascular risk factors
including obesity, hypertension, and dyslipidemia; there-
fore, the key elements of diabetes management need more
than drug consumption. Along with dietary and pharmaco-
logical interventions, Chinese acupuncture, Thai massage,
stretching exercise, and herbalism are employed by patients
in Thailand. In addition, Chinese traditional medicine,
particularly acupuncture, is a very popular treatment in
Vientiane of Laos for management of diabetes and rehabili-
tation.
and it remains an integral component of traditional Chi-
nese medicine today. Acupuncture is believed to restore and
balance energy flow or ‘‘qi.’’ Qi energy flows along chan-
nels in the human body called meridians. There are about
400 acupuncture points and 20 meridians connecting most
of the points.11,12 Acupoints may be stimulated by manu-
ally inserting needles and twirling them, or by applying a
small electric current (electro-acupuncture). In addition, it
may be used together with moxibustion (moxa) made from
dried mugwort, which is processed into a cigar-shaped stick.
Practitioners use moxa to warm regions and acupuncture
points with the intention of stimulating circulation through
the points and inducing a smoother flow of blood and qi.
The review conducted by the World Health Organization
suggested that acupuncture may help treat >20 medical con-
ditions, including cardiovascular disease.13,14
An important element of Eastern medicine is the con-
cept of life force or energy, which flows along specific
channels. In Chinese, it is called qi, whereas in Thai it
is called ‘‘loom.’’ Traditional Thai massage provides ben-
efits by stimulating pressure points to open the body’s
energy pathways, allowing energy to flow freely and the
body to heal itself. The combination of pressure on specific
points and yoga-like stretches in traditional Thai massage
relieves areas of muscular stress and tension. Additionally,
the studies suggested that it helps to improve the car-
diovascular system by dilating the blood vessels, so that
circulation is enhanced. It improves the responses of the
central nervous system. Several scientific studies support
that it can improve the immune system by invigorating the
nervous system and releasing toxins through improved cir-
culation; it is especially effective in releasing mental and
emotional stress.15—17 Some recent studies suggested that
massage is a proven, effective complement to traditional
diabetes management,18,19 including a study which revealed
that connective tissue massage improved blood circulation
in the lower limbs of patients with type 2 diabetes and
may be useful to slow the progression of peripheral arterial
disease.20
Patients living in Thailand, including Laos, have been
familiar with traditional herbalism for a long time. A great
diversity of medicinal plants in this region are used in sev-
eral herbal remedies to treat diabetes, and this knowledge
is passed down from generation to generation. Some of
these remedies have been proven for centuries to control
glycemia. In Thailand, and in Laos, practitioners who recom-
mend herbalism to the patients are mostly folk practitioners
living in the patients’ community. These are examples of
natural products that have long been used worldwide in tra-
ditional systems of medicine to treat diabetes, such as nopal
(prickly pear cactus), fenugreek, karela (bitter melon),

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CAMs for DM management in ASEAN countries 3

gymnema, ginseng, tronadora, chromium, and alpha-lipoic
acid.21
The last CAM in the study was exercise. Exercise should
be an integral component of a diabetes treatment pro-
gram because it is also a form of complementary therapy
and a way of promoting health that is both efficient and
effective.22,23 It was proved by several studies that appropri-
ate exercise is effective in improving blood pressure control,
lowering low-density lipoprotein cholesterol (LDL-C), and
elevating high-density lipoprotein cholesterol (HDL-C) levels
in people with diabetes.24
The phenomenological study reported in this paper inves-
tigated the experiences of DM practitioners and patients in
using acupuncture, massage, herbalism, or exercise in the
context of CAM to manage DM. The ultimate goal of this
study was to find effective and feasible practices to improve
the quality of life of DM patients that suits their economic
background and lifestyle.
Methods
This qualitative research was conducted in June to August
2013. Both participants, that is, practitioners and DM
patients, were recruited purposively by contacting the
practitioners and their patients with experiences in using
acupuncture, massage, herbalism, or exercise, for DM treat-
ment. Most of the practitioners work in hospitals, including
medical doctors, Chinese traditional acupuncture special-
ists, Thai traditional massage practitioners, and exercise
instructors for DM patient clinics in hospitals, and the rest
were folk practitioners who treat people with herbalism.
Most of these participants reside in the provinces of north-
eastern Thailand, and some were from Vientiane of Laos.
This yielded a total of 30 recruits, consisting of 15 practi-
tioners and 15 DM patients. The sample size was sufficient to
achieve data saturation. The inclusion and exclusion criteria
are shown in Table 1.
Table 1 Study inclusion and exclusion criteria.
Inclusion Exclusion
Practitioner Communication difficulty
Edu- Mental illness or learning
cated/trained/experienced disability
specifically to be a
practitioner
Experiences in successfully Vulnerability and frailty
caring DM patients with CAM
should not be less than five
cases
Patient
Having had DM
Used to be/being treated for
DM with conventional
medicine
Experienced any of CAM
alongside with conventional
medicine to care for/treat
DM
Phenomenology is particularly suited to the study of
people’s experiences with two points of view involving indi-
viduals such as practitioners and diabetic patients employing
Chinese acupuncture, Thai massage, stretching exercise, or
herbalism in conjunction with their medications;25 it can
enhance our understanding about the use of such a CAM in
the context of the ways of life of Thais and the neighboring
Laos.26
Methodologically, the study is consistent with principles
derived from the interpretivist paradigm, and it is par-
ticularly informed by Kvale’s27 framework for qualitative
interview-based research and by Van Manen’s28 framework,
which is both phenomenologically and hermeneutically sen-
sitive. The seven stages of interview structure27 include the
following: (1) thematizing, clarifying the overall purpose of
the interview; (2) designing, in relation to all seven stages
of the study; (3) interviewing, reflective and sensitively
designed; (4) transcribing, from oral to written text; (5)
analyzing, ensuring the method is appropriate for the pur-
pose; (6) verifying, addressing issues of trustworthiness; and
(7) reporting, ensuring clarity and ethical integrity. These
are related to the six concurrent stages of human science
research,28 consisting of the following: (1) turning to the
nature of living experience, (2) investigating experience as
living it, (3) reflecting on essential themes, (4) maintaining
a strong and oriented relation, (5) balancing the research
context, and (6) writing from a phenomenological perspec-
tive.
Ethical considerations
All participants were voluntary and all gave their informed
consent. The participants were informed about the purpose
of the study and the intended use of research data. They
were assured that they could withdraw from the study at
any time without recrimination. The participants were also
assured that the data would be treated in strict confidence;
a number would denote each participant and the partici-
pants’ identity would not be disclosed in the final report
or in any publication. Ethical approval was obtained from
the Minister of Health of the National Ethic Committee for
Health Research (NECHR), Laos’ People Democratic Republic
(No. 046/2013 NECHR).
Data collection
Prior to the interview, participants were asked to com-
plete a questionnaire that collected their demographic
data. The participants were asked with a broad and
open-ended question to narrate their experiences of using
Chinese acupuncture, Thai massage, stretching exercise, or
herbalism in their DM treatment with/without conventional
medicine. Narrative and contextual data were collected
during individual interviews with a single researcher. In
addition to the principles common to all qualitative inter-
views, the interview approach was also conducive to the
collaborative hermeneutic conversation,28 a multi-interview
approach that enables mutual reflection on data as a means
to explore and clarify meaning and to establish the signif-
icance of emerging themes. Field notes and diary entries
allowed for the researcher’s preconceptions; in addition,

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4 G. Pumthong et al.
participant observations during treatments were taken with
the camera and recorded as an additional source of data.
Data analysis
The data in this study consisted of narratives with inter-
viewees. To illuminate the meaning of the lived experience,
it was transcribed verbatim and subjected to content and
thematic analysis across and within groups of practitioners
and DM patients. Importantly, the experience of a phe-
nomenon remained private, but its meaning became public
by the interpretation. Thematic analysis occurred initially
at the level of individual transcripts, which were subse-
quently interpreted in the light of one another and, finally,
against additional data sources (personal, contextual, and
published). This allowed understanding to evolve beyond the
individual account to describe the phenomenon itself.
Following an initial, global interpretation of the text as a
whole, each transcript was subjected to a spiraling analysis
of the whole text in relation to each meaningful subunit of
the data, and vice versa. As units of meaning (preliminary
themes) began to emerge, they were verified or modified
against earlier interpretations and against field notes, until
data saturation occurred. Meaning was clarified and devel-
oped by scrutinizing the text for underlying beliefs and
assumptions that were implicit to participants’ accounts,
to produce final themes. These were subsequently analyzed
in relation to the other transcripts, to reveal ‘‘incidental’’
constituents of the phenomenon that also had potential rel-
evance to other contexts and, ultimately, the ‘‘essential’’
constituent.
Results
After long-term treatment with conventional medication,
both practitioners and DM patients sought a complementary
or alternative for more effective health care to relieve dia-
betic conditions and delay its progressive complications. It
was found that four different CAMs have been used in DM
management with or without conventional medicine, includ-
ing Chinese acupuncture, Thai massage, stretching exercise,
and herbalism. The demographic data of all participants are
shown in Table 2. The data indicated that all of patients have
type 2 diabetes.
As qualitative study design emphasizes the analysis of
each case, there is no requisite number of participants for
quality study, and therefore the sample size is usually small.
However, the study showed that the number of practition-
ers and patients was exactly 15 each, which was the same
number. Moreover, the numbers of males and females in the
study were comparable. These would balance the experi-
ences and opinions of those who give and who receive the
CAMs, in addition to no difference of gender preference.
Some patients described in Tables 2 and 3 used a com-
bination of more than one CAMs as treatment for health
care, for example, massage and acupuncture, massage and
herbalism, and acupuncture and herbalism. Most of the
patients were asked to perform stretching exercises in
conjunction with other activities. Notably, some of the par-
ticipants still used conventional medicine together with
CAMs, but some stopped using it altogether, particularly
Please cite this article in press as: Pumthong G, et al. Complementary and alternative medicines for diabetes mellitus
management in ASEAN countries. Complement Ther Med (2015), http://dx.doi.org/10.1016/j.ctim.2015.01.016
Table 2 Demographics (N = 30).
Variables Practitioner Patient (N = 15)
(N = 15)
Gender
Female 8 7
Male 7 8
Age (years)
<31 2 —
31—50 6 3
51—71 5 8
>71 2 4
Main CAM
Acupuncture 4 6
Massage 2 5
Herbalism 7 4
Exercise 2 —
those who alternatively used herbalism. All of the patients’
health improved and some DM symptoms were relieved to
some degree after taking any of the CAMs.
Each interview was read thoroughly several times to
capture the first understanding of the text as a whole,
following which the interpretation was conceived. In this
step of the analysis, the researchers considered their pre-
understanding as a resource. The text in Table 4 shows the
interpretation from the phenomenological data obtained
from the interview regarding experiences of using CAMs by
patients and practitioners in order to manage DM.
Chinese acupuncture
All acupuncture practitioners in the present study were
originally trained in China. One of them is a conventional,
medical doctor who said, ‘‘Acupuncture could help my
patients to reduce using a long term DM drugs, and therefore
it could delay the damage of their kidney and liver.’’ All of
the practitioners said in common that ‘‘Acupuncture could
delay the progressive DM complications, and helped relieve
pains, sciatica, fatigue, and especially neuropathy of limps
which were basically found in these patients.’’ These data
were obtained from observation of all practitioners with
long-term treatment. An acupuncture doctor in Laos said
that ‘‘it would give more efficacy if the patients do massage
or cupping to enhance blood flow before acupuncture.’’
On the other hand, most of the patients were of the
views that ‘‘acupuncture effectively relieved pains, sciat-
ica, blurred vision, and neuropathy, which were the main
causes to take drugs, and so that it can reduce drug use.’’
They felt healthier and gained more energy after undergoing
acupuncture.
Thai massage
Most of the practitioners and patients agreed in common
that Thai massage helped relax and enhance blood cir-
culation. Particularly foot massage can help reduce the
incidence rate of limb amputation. A practitioner had
treated her patients with the combination of massage and
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CAMs for DM management in ASEAN countries 5

Table 3 DM-related information on patients.

Patient Symptoms before CAM Blood sugar (mg%) Conventional Using CAMs Results after applied
use (Last testing) method CAMs

1 Pain, sciatica, chronic 142 Not any more Acupuncture CAMs help reduce
wound on hand pains and help cure
chronic wound
2 Pain, fatigue, 109 Taking insulin, Acupuncture and Used to have blood
neuropathy sometimes stretching sugar >402 mg%
before CAM use
3 Much fatigue, 160 Still taking but less Acupuncture Able to maintain
neuropathy blood sugar level, and
feel energized
4 Fatigue, blurred vision, 182 Not any more after Acupuncture and Can walk without
neuropathy, walk with taking long term massage stick and overall
stick symptoms improving
5 Pains, numbness in hands 216 Still taking but less Massage and Overall symptoms
and feet stretching improving
6 Pains, numbness in hands 141 Still taking Massage and Less pains and less
and feet acupuncture numbness. Stop using
pain drugs
7 Fatigue, blurred vision, 105 Gemfibrozil Massage The overall diabetic
numbness in hands and symptoms very
feet improved
8 Numbness 100 Enalapil and Massage Much improved
metformin numbness
9 Full-time nursing, 150 Metformin Acupuncture and Much less pains and
fatigue, and numbness massage numbness after CAM
use, and can walk
10 Cardiovascular 108 No more oral drugs Herbalism and Liver flushing,
complications, stretching sometimes. The
hypertension symptoms very much
improved
11 Hypertension, numbness 157 Still taking but Herbalism and Maintain good health,
need to stop massage and can control blood
sugar not too high
12 Numbness, itchiness, 169 Oral drugs Massage and Combined with
hypertension, cardio-, exercise meditation and liver
nephro-, and flushing improved
neuropathies symptoms
13 Fatigue, cardio, 141 Long-term use Herbalism Intestine detox
hypertension, ureteric with insulin and sometimes.
stone oral drugs but still Symptoms improve
DM progress after mainly taking
herbs
14 Fatigue, blurred vision, 150 Stopped Herbalism The overall symptoms
numbness, cardio and combined with were very improved
hypertension acupuncture
15 Cardio, hypertension, 144 Insulin and oral Acupuncture and Get energized and
and numbness drugs cupping improved good health

acupuncture, and the result proved this to be a more effec-
tive method of controlling blood sugar and helping patients
maintain good health, if it occurred regularly.
Herbalism
Mostly, the patients tried herbalism alternatively after long-
term, ineffective conventional drug consumption. Herbalism
was used as an alternative so that patients learn to take care
of themselves at home. One patient managed her diabetes
by taking herbal remedies prescribed by a folk practitioner
to control hyperglycemia, after a long-term conventional
treatment. She claimed that ‘‘it really reduced blood sugar
and easy to be accessible.’’ Folk practitioners used ingredi-
ents that were readily found in their community, rendering
these remedies considerably cost-effective.

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Table 4 The interpretation of phenomenological data from the experiences of using CAMs by patients and practitioners to
treat DM.

CAMs Practitioners’ experiences Patients’ experiences

Chinese Importantly reduces drug consumption leading to
acupuncture less risk of liver/kidney damage greatly found in
chronic DM patients
Effectively treats the symptoms normally found in
DM patients such as pains, sciatica, fatigue, and
especially neuropathy of limps
Delays the progressive DM complications
More efficacy if massage or cupping is done to
enhance blood flow before acupuncture
Able to restore good health and delay
complications in DM patient with a regular
treatment and a certain duration depending on
each case
Thai massage Helps the patients feel relaxed so that
hyperglycemia and some pains can be reduced
Enhances blood flow so that neuropathy of feet
and chronic wounds are reduced, thus less
amputation if done regularly
Helps stretch muscle and lessen muscle tension
More efficacy if combined with acupuncture
Herbalism Some herbal remedies that have been
traditionally used for a long time were found to
more effectively reduce hyperglycemia
Mostly patients tried herbalism alternatively after
long-term, ineffective conventional drug
consumption
Become gradually healthier with time with care
provided by practitioners
Patients learn to care for themselves at home
with herbalism
Stretching It is an essential complementary for DM
exercise treatment, although not used alone for the
treatment
Stretching was found to be an appropriate
exercise for DM patients who are mostly elderly
and ill, with some reasons, such as not to work
hard and easy to follow, able to do it at any place
or time, no need of sport outfit and sport wares,
and importantly help stretch muscle and tendon,
and also enhance muscle strength
Able to take less or stop taking conventional
treatment
Obviously feel more energetic immediately after
acupuncture
Effective relief of pains, sciatica, blurred vision,
and neuropathy, which were the main causes for
taking drugs and visiting the doctor
Promotes health in patients with hypertension,
cardiovascular diseases, neuropathy, and
nephropathy with a particular duration of regular
treatment
Feel healthier with/without conventional
medicine
Some tried it as a complementary, but some as an
alternative
Cheap and effective
Feel relaxed and happier after foot/body
massage, although not sure it can reduce glycemia
Feel relief
Good for hand and foot numbness
Most tried it as a complementary
Self-foot massage is good to practice at home
Not expensive and works
Readily relieves diabetic symptoms such as
chronic wounds, fatigue, booting energy, and
particularly hyperglycemia
Natural healing
Effectively controls hyperglycemia
Taken as an alternative medicine
Much cheaper because most of the herbs can be
easily found in the community
A complementary combined with the conventional
or alternative treatment
Practice regularly to improve health readily
Quite simple but works better
No cost

The study found that herbs used to treat DM Stretching exercise

patients officially sold by the Institute of Traditional
Medicine in Laos included Centella asiatica, Andro-
graphis paniculata, Momordica charantia, Orthosiphon
aristatus, Catharanthus roseus, Albizia myriophylla, and
Anacardium occidentale. Some DM patients in Thailand
have used a traditional remedy composed of Mallotus
repandus (75%), Azadirachta indica (20%), and Tinospora
crispa (5%). These herbs can help successfully reduce
hyperglycemia.
Stretching exercise, including yoga, taichi, and Thai her-
mit exercise, was a kind of complementary medicine for DM
patients, which was very helpful, cheap, and easily acces-
sible. Practitioners said, ‘‘It worked when combined with
any other of conventional and alternative medicine.’’ They
taught patients how to perform the stretching exercise in
order to work out at home or any place, at any time, for
10—15 min daily.

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CAMs for DM management in ASEAN countries
Table 5 Concluding good practices of using CAMs derived
from the interviews to promote good health for DM
management.
CAMs Practice
Acupuncture Regularly, once a week to treat diabetic
conditions including pains, sciatica,
neuropathy, and complications of
cardiovascular diseases
Once/twice a month to maintain good
health and delay complications
Foot massage Regularly, once a week to cure diabetic
complications such as pains and
numbness of limbs
A few times a month to stretch muscles
and to relax and for relief
Self-foot massage at home every day to
reduce chronic wound, and finally
amputation
Herbalism An alternative medicine of nature
healing and self-care for daily control of
hyperglycemia
Use of herbalism depending on the
remedies, and upon DM conditions
Stretching An easy complementary medicine to be
exercise practiced daily, to readily improve
health and reduce hyperglycemia
Obtained from the interviews of practitioners and
patients, the concluding good practices that were regu-
larly employed to promote good health in DM patients are
shown in Table 5. The table concluded the experiences
of practitioners and patients of managing diabetes and
employing them as good practices. In brief, acupuncture
and massage should be performed regularly, even though
the frequency depends individually upon the DM conditions
of the patients, or the practitioners’ diagnosis. Herbalism is
an alternative medicine of nature healing and self-care to
control hyperglycemia daily, whereas stretching exercise is
a complementary medicine that patients can perform daily
by themselves to readily improve their health and control
hyperglycemia.
Discussion
Health care was deemed effective only when it met
each of the six essential criteria, including symptomatic
relief; repair and recovery at physical, emotional, and
psychological levels; absence of side effects; collabo-
rative patient—practitioner relationship; no recurrence of
illness (unless unavoidable); and minimal disruption to
daily life. These were realized through three interde-
pendent processes (incidental constituents): dealing with
illness causation, patient—practitioner collaboration, and
the provision of authentic health-care evidence.29 All four
CAMs studied, including Chinese acupuncture, Thai mas-
sage, stretching exercise, and herbalism, were perceived
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management in ASEAN countries. Complement Ther Med (2015), http://dx.doi.org/10.1016/j.ctim.2015.01.016
7
as effective because it met these criteria more readily than
conventional medicine.
The CAMs in the present study are selectively beneficial
to promote health and delay complications in DM patients.
Acupuncture has been increasingly used for the manage-
ment of pain and other acute/chronic conditions in various
clinical settings.30—33 When acupuncture is used as a sole or
adjunctive treatment in general practitioner (GP) practices
or tertiary hospital settings, better health outcomes and
less analgesic consumption after acupuncture treatments
were observed, which might contribute to the reduction
of potentially harmful drug overconsumption. Acupuncture
is effective in the modulation of the expression of nitric
oxide synthase (NOS) in the periaqueductal gray area of
rats under diabetic conditions.34 Nitric oxide (NO), synthe-
sized from L-arginine through calcium-dependent pathways
by NOS, is a free radical with signaling functions in the
central nervous system. NO has been implicated in the reg-
ulation of autonomic functions, and it has been shown to
play important roles in the neural, vascular, and immune
systems.35
Massage is a proven, effective complement to traditional
diabetes management.17—20 The reasons that massage ther-
apy are beneficial to diabetics are follows. First, massage
provides relaxation. When the body encounters stress, it
prepares itself for a ‘‘fight-or-flight’’ reaction by raising
blood glucose levels. It has confirmed that stress manage-
ment can lower blood glucose levels. A Touch Research
Institute study demonstrated that massage therapy lowers
blood glucose levels in children with DM. A study showed that
a short stress-relief program including touch could lower
blood sugar and improve health in diabetic patients.36 Sec-
ond, massage can increase circulation, thereby encouraging
the efficient transport of oxygen and nutrients throughout
the body. Improved circulation, in turn, improves the cells’
insulin uptake. Lastly, massage enhances tissue flexibility.
It helps increase tissue mobility and elasticity, reversing
the thickening effect of uncontrolled glucose levels. Tissue
inflexibility can manifest as stiffness in muscles, tendons,
and ligaments, as well as a decreased range of motion in
the joints.
Additional factors contributing to the flexibility and
health of the myofascial system include range-of-motion
techniques, stretching, and the inclusion of a regular exer-
cise program. Therefore, physicians should recommend
exercises for DM patients who can do so safely. The study
suggested that stretching is not only a form of complemen-
tary therapy but also a way of promoting health, which is
both efficient and effective. Therefore, the exercise can
work well as a complementary health care.
To date, several natural products in common use are
apparently able to lower blood glucose levels to treat DM.
Commonly used natural products often have a long history of
traditional use, and pharmacists who have a stronger under-
standing of these products are better positioned to counsel
patients on their appropriate use.21 As Asian countries are
rich in herbs and therefore herbal remedies traditionally
proven to be efficient and safe, herbalism should be seri-
ously promoted as CAMs for DM treatment in this region.
Herbalism can be a potential treatment for DM management
for people residing in this region as it is cost-effective and
suitable to the lifestyles of the ASEAN community.
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8 G. Pumthong et al.
The CAM approach is increasingly capturing the interest
of the general public. It is indicative of how communities
and consumers are moving beyond a dominant biomed-
ical science approach and a health-care infrastructure
based on this. It integrates community-based participatory
approaches, and it has the potential to help generate a uni-
fying voice in the prevention and control of chronic diseases,
particularly DM.4
The limitations of the study were the lack of scien-
tific proof regarding the data derived from the subjects’
experiences. Therefore, more research is needed. Future
conceptual development such as clinical trials investigat-
ing each or a combination of the CAMs, including Chinese
acupuncture, Thai massage, and stretching exercise, and
a pharmacological study of the herbal remedies on mul-
tiple symptoms of DM can be considered. However, each
single case presented within the scope of this paper can
be dialectically understood as both individual and universal,
and theoretically saturated and representative in its data
and findings.37 The discussion has been opened, and these
concepts might and should be part of future debates so as
to fill the existing knowledge gaps.
Conclusion
The study explored and revealed the social perceptions
of practitioners and patients using Chinese acupuncture,
Thai massage, stretching exercise, and herbalism, as CAM
for DM health-care management. The phenomenological
perspective was interpreted using content and thematic
analysis. Perceptions of the involving persons attributed to
patient—practitioner consensus in DM treatment with these
CAM practices, with or without conventional health care,
can hold a key to a more comprehensive health care. It is a
means to expand the boundaries for contemporary health-
care provision.
Acknowledgments
We would like to thank the practitioners and patients, resid-
ing in Thailand and in Vientiane of Laos, for participating
in this study. We also want to thank Anousone Sisulath who
coordinated the research during data collecting in Laos. The
study was supported by the 2013 project of studying educa-
tion and culture with networking universities in the ASEAN
Economic Community.
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