Over 80% of the populations in developing countries depend on CAM products and/or traditional healing modalities, including herbal remedies, for health maintenance and therapeutic management disease [14, 15, 18, 20]. As in other developing regions, CAM and herbal remedy use is common in Saudi Arabia to deal with diabetes and its complications [12–16, 21]. Al-Rowais et al. [15, 21] studied the different types of CAM uses in Riyadh, Central Saudi Arabia and found that herb practitioners were the most popular compared to the other modalities of CAM. In another study in Riyadh [21] 17.4% of studied diabetics reported using some form of herbs. The commonest herbs used were myrrh, black seed, helteet, fenugreek and aloes. However these reports were limited to the oral route of using CAM products.
DFD are fairly common among diabetic patients in our sample. It came as the second diabetes complication in order after eye problems in at least two thirds of the patients, in previous years once or more. The chronicity and recurrence of DFD may explain the preferential use of topical CAM products by significant proportion of our sample as half of the group studied used some sort of CAM topical treatment alone or in combination with conventional one.
The fears of limb loss will influence diabetic patients to try all types of conventional and CAM products aiming to avoid the tragedy of amputation. Most patients and sometimes health professionals tend to deal with DFD as local problem and therefore focus on using local topical agents which may prevent infection or promote healing such as honey [16, 22].
Up to the best of our knowledge, nothing was published on the uses of CAM among diabetic patients in topical care of diabetic foot disorders DFD such as open wound, chronic ulcer, infected in-growing nail, and skin cracks. Such information is needed for research plans in such local complications of diabetes. For this reasons we decided to explore the magnitude of the problem and identify the CAM products and preparations preferred by our local community. Similar patterns are expected in the nearby countries of similar cultural backgrounds including Islamic, Arabs, Asians, Africans and Middle Eastern countries.
Many studies identified the increasing prevalence of herbal use throughout the world among diabetics [12–14, 21, 22] however, herbal remedies were not considered as an entity on its own, but as a subset of complementary and alternative medicines. In this study we noticed that diabetics used different types of natural products e.g. honey, Myrrh (Commiphora Molmol); herbal seeds e.g., Black Seeds (Nigella Sativa); and medicinal plants e.g. Saber (Cactaceae), Helba (Fenugreek). For this reasons it may be more accurate to label this use under the broad term of CAM particularly when patients mix more than one entity with another.
The use of CAM products is common among diabetic patients [12–15, 18, 22, 23] including those in Saudi Arabia [21]. The aim of our study was to determine the prevalence of the use of CAM products among diabetics and which products are preferentially used for topical care of DFD. In this regard, we found that honey headed the list as more than half of the diabetic patients (56.6%) who had history of foot ulcers/disorders indicated that they have used honey for dealing with it either alone or in combination with other topical remedies. This was not a surprise as many doctors/nurses realized that patients in this part of the ancient world are used to adopt this on daily basis for local care of wounds not only currently but over millennia [16, 22, 24] irrespective of the insufficient published clinical evidence which supports its use. Jull et al. [16] reviewed systematically the use of honey in topical treatment of various wounds including wounds in diabetics. They identified 19 trials (n = 2554) that met their inclusion criteria and concluded by critiquing most of them due to their poor quality. According to Jull et al. [16], there is insufficient evidence to guide clinical practice for diabetics' wounds. A Malaysian comparative study between honey and povidone iodine as dressing solution for Wagner type II diabetic foot ulcers showed insignificant difference in ulcer healing in both study groups [25]. However, they concluded by stating that honey dressing is a safe alternative dressing for diabetic foot ulcers as it enhances wound healing, prevents superadded infection and it is readily available with affordable cost in most of developing countries as stated by various studies in literature [16, 23, 25–27]. The absences of randomized control trial RCT does not necessarily mean that honey should not be used as there are many studies advocating it use particularly those done on Manuka honey by Peter Molan et al. of New Zealand [26]. An RCT on the use of honey in treating diabetic foot ulceration is on-going by Jennifer Eddy of Wisconsin, USA [27]. Given honey's potential for improved outcomes, cost savings, and decreasing antibiotic use and resistance, we agree with others [22, 25–27] to consider topical honey therapy for patients with refractory diabetic foot ulcers particularly in countries where patients wish to use honey topically in treating their foot problems.
The second CAM product used by our patients was Commiphora Molmol (Myrrh) which was used topically by (37.4%) of our sample and in combination with Honey in (12.1%). Commiphora Molmol (Myrrh) is one species of the resin-bearing plants grew across the Red Sea in the area that is now Somalia and Ethiopia, while the collection of the gum resins was initiated in Arabia. Recent studies have focused on applying clinical trial methodologies to validate its use as an antineoplastic, an antiparasitic agent, and as an adjunct in healing wounds [28, 29]. It was prescribed for treating skin infections and periodontal abscesses [29]. It has also some s antibacterial and antifungal activity against standard pathogenic strains of Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa and Candida albicans [30].
The third preferred CAM product used was Nigellia Sativa (Black seed) which was used by (35.1%) in treating DFD and in combination with honey in 19.1% of our sample. Nigella sativa (Black seed) has been used for medicinal purposes for centuries, both as a herb and pressed into oil, in Asia, Middle East, and Africa. It has been traditionally used for a variety of conditions and treatments related to respiratory health, stomach and intestinal health, kidney and liver function, circulatory and immune system support, as analgesic, anti-inflammatory, anti-allergic, antioxidants, anticancer, antiviral and for general well-being The seeds contain both fixed and essential oils, proteins, alkaloids and saponin [31]. Much of the biological activity of the seeds has been shown to be due to thymoquinone, the major component of the essential oil. The seeds are characterized by a very low degree of toxicity. However, only two cases of contact dermatitis in two individuals have been reported following topical use [32]. Different crude extracts of Nigella sativa were tested for antimicrobial effectiveness against various bacterial isolates which showed multiple resistances against antibiotics by Morsi of Cairo [33]. Gram negative isolates were affected more than the gram positive ones [33]. Most of our patients used the crude extracts.
Few limitations must be addressed in our study. The first is the method of sampling and the second is the tool used in investigation. With regard to sampling, the targeted sample in this study was not randomized however; we think it was a representative convenient sample as interviewers were distributed across all districts in Jeddah city. Any known diabetic who was living in studied districts was considered eligible to be enrolled. Although we attempted to use convenient and advantageous capturing of our sample, it may have been possible that interviewer bias may have been introduced by the non-random selection of patients, resulting in a sample that may not have been truly representative. Another limitation was the lack of inter-observer variability assessment of the "hom-made" questionnaire which was constructed by the authors based on their local experience and not on similar well validated tools. The lack of information on the proportion of patients who refused to participate in the study is another weakness analyzing the data.
We were therefore suspicious about whether the respondents have given reliable answers to the questionnaire's items particularly the uneducated ones and those of low social group. In this regard, we think that respondents were reliable to great extent in our sample as we found significant association between longer duration and lack of control on diabetes and the prevalence of DFD as defined. Furthermore, their answer to the indirect question which aimed to assess the patient general knowledge about the relation between foot complications and lack of commitment to dietary restrictions was correct in (75.8%) of the sample as they knew that there is a direct relationship between the development of frequent foot ulcers and unhealthy dieting.
Notwithstanding these limitations our study results indicate that the high prevalence of CAM products use in Jeddah, Saudi Arabia may be attributable to the patients' underlying belief that these herbs are efficacious and in some cases more efficacious than conventional medicines. This high prevalence of CAM products use leaves us with little option but to accept that this modality would be around for some time and that important public health concerns must be urgently addressed. We therefore recommend that physicians become more knowledgeable about herbs so that they would be better able to communicate with their patients, especially with regard to their potential interactions with conventional medicines. We also support the conducting of well-designed controlled clinical trials to establish the safety profile and efficacy of the commonest medicinal herbs and or natural products used by our diabetic patients. These evidence-based studies would provide a platform for informed decisions by healthcare providers and more importantly the self-prescribing members of the public.
Furthermore, information about the common CAM products and preparations will help physicians in outlining interventional plans of diabetic foot disorders. Future research in similar countries should be based on local patients' concepts and practices in dealing with diabetic foot disorders particularly ulceration. These practices should be taken in consideration when outlining local future health plans for diabetic foot disorders in Saudi Arabia and perhaps in other countries of similar cultural background including Middle Eastern and nearby African countries.
