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There is little published on current Saudi diabetic patients' practices when they are exposed to foot disorders such as open wound, ulcer, and skin cracks.
A Cross-sectional descriptive study of a representative cohort of diabetic patients living in Jeddah, Saudi Arabia was designed. The use of CAM products in topical treatment of diabetic foot disorders is fairly common among Saudi diabetic patients.
BackgroundDiabetes is a chronic debilitating medical condition that affects at least one out of five Saudis i.e. Types of treatment used in dealing with foot disorders as reported by 653 diabetics (64.9% of those reported foot disorders).
The top ten common combinations of CAM products used for treating diabetic foot disorders topically were also identified. Top ten combinations of CAM products used for treating diabetic foot ulcers by the studied diabetic patients. We were also interested to identify our patients' sources of information about CAM medicine and natural remedies. Competing interestsThe authors declare that they have no competing interests.Authors' contributionsBB conceived of the study and both authors contributed to its design.
A pre-designed questionnaire to identify local diabetics' practices in dealing topically with foot disorders including open wound, chronic ulcer, and skin cracks was designed.
Honey headed the list as a solo topical preparation or in combination with other herbs namely black seeds and myrrh.
The sample was a convenient sample which was collected over two month's period (March and April 2008). As in other developing regions, CAM and herbal remedy use is common in Saudi Arabia to deal with diabetes and its complications [12a€“16, 21].
The aim of the current study was to identify the pattern of patients' use of CAM products in dealing with diabetic foot disorders topically in a group of diabetic patients. Questionnaire was administered by a group of trained nutrition female students to diabetics face to face living in their neighborhood. Data was collected by a group of 40 trained final year undergraduate nutrition female students as part of their research module. Therefore, it is a major public health problem in Saudi Arabia, Gulf States and most Middle Eastern countries. All of these natural or CAM products are available in the local market and are sold without regulations. Alnozha et al quoted an overall prevalence rate of diabetes in Saudi which reached up to 23.7% [2]. This wide comprehensive distribution of the studied clusters enhanced the representation of all the socio-economic groups of Greater Jeddah's communities which embraces more than 2.5 million inhabitants. In another study in Riyadh [21] 17.4% of studied diabetics reported using some form of herbs.
Training and overall supervision of the interviewers were carried out by the principle investigator (BB).Interviewers were requested to recruit any known diabetic patients living in their neighborhoods including relatives, neighbors and friends. The median number of times for frequency of foot disorders among respondents accounted for 2 times. Ulcer is the most common presentation in diabetic foot disorders as reported by our group over the last two decades [3, 4]. However these reports were limited to the oral route of using CAM products.DFD are fairly common among diabetic patients in our sample.

Each interviewers was requested to enroll approximately 40 patients (range 35-45 patients from each district) to ensure fair representations from all of Jeddah's districts.
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.
Ten common natural preparations used topically to treat diabetic foot disorders were also identified. When amputation happens, it is usually associated with significant morbidity [6] and mortality [7a€“9], in addition to immense social, psychological and financial consequences [10, 11].Self-medication with oral natural preparations and herbs are fairly common as part of complementary and alternative medicine (CAM) which is used by individuals with and without diabetes [12a€“14]. Verbal informed consents were obtained after the study had been explained to them in native language. 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.
The study was approved by the ethical committee of King Abdulaziz University Hospital (Ref. 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. In developing countries, people believe that natural products and herbal formulations are preferred due to lesser side effects and lower cost [14]. For this reasons we decided to explore the magnitude of the problem and identify the CAM products and preparations preferred by our local community. Evidence from animal studies and some trials has suggested that honey may accelerate wound healing [16]. For the sake of study's purpose, foot disorder was defined as one or more of the following presentations "open wound, chronic ulcer, infected in-growing nail, and skin cracks".
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 [12a€“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 Saudi Arabia, some herbs, natural products and CAM preparations are occasionally added to honey or used separately by diabetics as seen in daily practices.
We aimed to identify the proportion of those who preferred conventional treatment versus those who had traditional i.e. 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 [12a€“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. Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables, and means and standard deviations for quantitative variables. Quantitative continuous data were compared using Student t-test in case of comparisons between two groups.
When normal distribution of the data could not be assumed, the non-parametric Kruskal-Wallis or Mann-Whitney tests were used instead of Student t-test. Whenever the expected values in one or more of the cells in a 2A—2 tables was less than 5, Fisher exact test was used instead. They identified 19 trials (n = 2554) that met their inclusion criteria and concluded by critiquing most of them due to their poor quality.
Pearson correlation analysis was used for assessment of the inter-relationships among quantitative variables.
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, 25a€“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. An RCT on the use of honey in treating diabetic foot ulceration is on-going by Jennifer Eddy of Wisconsin, USA [27]. 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]. 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. 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].
Most of our patients used the crude extracts.Few limitations must be addressed in our study. 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.
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.

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