CAM Practice Exam: Diabetes Chapter 22

With 25% to 57% of people with diabetes reporting the use of complementary or alternative medicine, it is essential for healthcare professionals to understand the current evidence base. While many patients seek these therapies to align with their values or due to dissatisfaction with conventional care, the evidence for efficacy and safety varies significantly.

This practice exam tests your knowledge of the 2018 Clinical Practice Guidelines regarding Natural Health Products (NHPs), mind-body practices, and the critical importance of identifying potential drug-herb interactions.

Key Concepts Covered in This Exam:

Prevalence & Disclosure: Recognizing the high rate of CAM usage and the recommendation that healthcare providers must actively ask patients about their use of these therapies.
Evidence of Efficacy: Identifying which NHPs have shown potential A1C reduction ( $\ge$ 0.5%) in small trials (e.g., fenugreek, flaxseed) versus those that have failed to show consistent benefit in larger trials (e.g., cinnamon, chromium, vitamin D).
Safety & Regulation: Understanding the risks of adulteration and the importance of using products with a Natural Product Number (NPN), as well as specific risks like hepatotoxicity or hypoglycemia.
Drug Interactions: Knowing well-documented interactions, such as the effect of St. John’s Wort on cytochrome P450 3A4 (CYP3A4) and its impact on statins and other medications.
Mind-Body Modalities: Reviewing the evidence for non-pharmacologic approaches like yoga, which may offer benefits for glycemic control and lipid profiles.

1. A patient asks about chromium supplementation for diabetes. What should you tell them about the evidence?

Meta-analyses have reported conflicting results
Chromium is strongly recommended for all people with diabetes
Chromium always lowers A1C by at least 1%
Chromium is contraindicated in diabetes

2. To avoid adulteration with unlabelled pharmaceuticals or contaminants, which products should be recommended to patients?

Any product labelled as “natural”
Only NHPs properly labelled with a valid natural product number (NPN)
Products recommended by friends and family
Products purchased from international websites

3. What does the evidence show regarding tai chi for glycemic control in diabetes?

Evidence of harm
Strong evidence of significant A1C reduction
Little evidence for benefit on glycemic control
More effective than yoga

4. Which factors are independently associated with CAM use among people with diabetes?

Male sex and rural residence
Younger age and lower education
Lower income and longer diabetes duration
Older age (≥65 years) and higher educational attainment

5. A patient with type 2 diabetes is taking Tinospora crispa, a traditional herbal remedy. They report feeling unwell with nausea and fatigue. What serious adverse effect has been reported with Tinospora crispa?

Renal failure
Hepatotoxicity
Severe hypoglycemia
Cardiac arrhythmia

6. Which of the following NHP has demonstrated ≥0.5% A1C reduction in randomized controlled trials lasting at least 3 months?

Ginseng
Vitamin C
Berberine
Vitamin E

7. According to meta-analysis comparing yoga, walking, and tai chi, which was most effective for lowering A1C when performed regularly (3 times per week)?

Tai chi
Yoga
All were equally effective
Walking

8. Which natural health product has properties including insulin secretagogue, PPAR, and alpha-glucosidase activities?

Cinnamon
Chromium
Nettle (Urtica dioica)
Vitamin D

9. A patient with type 2 diabetes and hyperlipidemia is interested in berberine, which they heard can help with both conditions. What did meta-analysis show about berberine’s effects on lipids?

Reduced TG and increased HDL-C more than traditional lipid-lowering drugs
Only effective for high LDL-C
Worsened lipid parameters
No effect on lipids

10. A patient with type 2 diabetes and diabetic nephropathy asks about natural products that might help their kidney function. Which category of products has shown reduction in urinary albumin excretion in diabetes?

Probiotics
Chromium supplements
Several traditional Chinese medicines (e.g., Tangshen Formula, Huangshukuihua)
Omega-3 fatty acids

11. What is the evidence regarding randomized controlled trials of vitamin D supplementation on glycemic control in diabetes?

Vitamin D significantly improves A1C
No studies have been conducted
Vitamin D is harmful in diabetes
Vitamin D has not demonstrated benefit on glycemic control

12. What percentage of people with diabetes report using complementary or alternative medicine (CAM)?

80% to 95%
60% to 75%
5% to 15%
25% to 57%

13. A 58-year-old woman with type 2 diabetes and painful diabetic peripheral neuropathy asks about natural treatments for her nerve pain. Which NHP has shown benefit for painful diabetic neuropathy in a randomized controlled trial?

Omega-3 fatty acids
Magnesium
Vitamin E
Topical bitter apple extract oil

14. A 48-year-old man with type 2 diabetes is interested in trying bitter melon (Momordica charantia) supplements, which his relative recommended. What important safety information should you provide about Momordica charantia?

It is an abortifacient
It can cause severe hypoglycemia
It interacts with all diabetes medications
It causes hepatotoxicity

15. A 55-year-old woman with type 2 diabetes tells you she has been taking cinnamon supplements for 3 months to help control her blood sugar. She asks if this is effective. What is the evidence regarding cinnamon for glycemic control in type 2 diabetes?

Proven to be harmful
No studies have been conducted
Conflicting effects on A1C in trials
Strong evidence of significant A1C reduction

16. What is the minimum A1C reduction threshold used in the guidelines to identify promising natural health products for diabetes?

≥0.5%
≥1.5%
≥1.0%
≥0.3%

17. A patient with type 2 diabetes asks about taking coenzyme Q10 (CoQ10) supplements for their diabetes. What does the evidence show regarding CoQ10 and glycemic control?

No studies have been conducted
Conflicting effects on A1C in trials
Proven to worsen glycemic control
Consistent evidence of significant A1C reduction

18. A 50-year-old woman with type 2 diabetes and a recent myocardial infarction asks about EDTA chelation therapy, which she read can help with cardiovascular disease. What did the TACT trial show regarding EDTA chelation therapy in people with diabetes and prior MI?

No benefit in any subgroup
A 39% to 41% risk reduction in cardiovascular complications in the diabetes subgroup
Increased cardiovascular events
The study was terminated early due to harm

19. A patient asks about using acupuncture to improve their diabetes control. What does the evidence show about acupuncture and A1C in diabetes?

Acupuncture is the most effective CAM for diabetes
No studies have examined acupuncture and diabetes
Acupuncture has not been shown to improve A1C
Acupuncture significantly lowers A1C

20. According to Canada’s Natural Health Products Regulations, which of the following is NOT classified as a natural health product (NHP)?

Probiotics
Traditional Chinese medicines
Herbal remedies
Prescription medications

21. According to the guidelines, what is the first step health-care providers should take regarding CAM use in patients with diabetes?

Recommend specific NHP products
Refer to a naturopath
Ask about the use of CAM
Discourage all CAM use

22. Which of the following correctly describes the relationship between omega-3 fatty acids and type 2 diabetes risk in observational studies?

Benefit only in Caucasians
Increased intake of ALA and fatty fish reduced risk;
Increased diabetes risk with omega-3 intake
No association

23. What does the evidence show regarding bitter melon’s effect on A1C?

Failed to lower A1C by 0.5% in trials lasting at least 3 months
Causes A1C to increase
Consistent significant A1C reduction
No studies exist

24. A patient with type 2 diabetes mentions they are taking fenugreek (Trigonella foenum-graecum) supplements. What common adverse effect is associated with fenugreek?

Gastrointestinal effects
Hepatotoxicity
Severe hypoglycemia
Nephrotoxicity

25. According to the Medical Expenditure Panel Surveys (MEPS), how much more likely are people with diabetes to use CAM compared to those without diabetes?

2.0 times
2.5 times
1.2 times
1.6 times

26. A 52-year-old woman with new-onset type 1 diabetes participated in a trial of vitamin D supplementation to preserve beta cell function. What was the outcome of the randomized controlled trial of vitamin D in new-onset type 1 diabetes?

Worsened autoimmunity
Prevented progression to insulin dependence
Complete preservation of C-peptide
Improved Treg suppressive capacity but no significant reduction in C-peptide decline

27. What is the definition of “complementary” medicine in the context of CAM?

Used in place of conventional medicine
Approved by Health Canad
Only uses natural products
Used together with conventional medicine

28. A patient with diabetes and osteoarthritis is taking glucosamine sulfate. They are worried this might affect their blood sugar control. What does the evidence show about glucosamine and glycemic control?

Glucosamine is contraindicated in diabetes due to the high glucose content
A systematic review concluded that it does not worsen glycemic control
Glucosamine consistently worsens glycemic control
Glucosamine improves A1C

29. For which diabetes complication has acupuncture shown some benefit?

Nephropathy
Diabetic gastroparesis
Cardiovascular disease
Retinopathy

30. A patient with type 2 diabetes shows you a bottle of “Xiaoke Pill,” a traditional Chinese medicine they purchased online for diabetes. What important information should the patient know about this product?

It contains glibenclamide (glyburide
It is approved by Health Canada
It has no effect on blood glucose
It is purely herbal with no pharmaceutical ingredients

31. Which traditional Chinese medicine was shown to reduce progression from impaired glucose tolerance (IGT) to type 2 diabetes by 32%?

Berberine
Jinlida
Xiaoke
Tianqi

32. A 60-year-old man with type 2 diabetes is frustrated with his current treatment and wants to stop his metformin to use only “natural” products. What is the guideline recommendation regarding CAM efficacy and safety for diabetes?

CAM is proven more effective than conventional therapy in some patients
CAM should replace all his conventional medications
CAM can be considered as first-line therapy
There is insufficient evidence to make a CAM recommendation

33. What is the primary concern regarding the current level of evidence for NHP in diabetes?

Trials tend to be of shorter duration with smaller sample sizes
NHP are too expensive
NHP are not widely available in Canada
All NHP have been proven ineffective

34. A 62-year-old woman with type 2 diabetes is taking a statin for hyperlipidemia. She mentions she started taking St. John’s wort (Hypericum perforatum) for mild depression. What is the concern with this combination?

There is no interaction
St. John’s wort induces CYP3A4
St. John’s wort causes hypoglycemia
St. John’s wort increases statin levels

35. A 45-year-old man with type 2 diabetes is interested in trying yoga to help manage his diabetes. What does the evidence suggest about yoga for type 2 diabetes?

Yoga is not recommended in diabetes
Meta-analyses show positive effects on reducing A1C
No benefit has been demonstrated
Yoga worsens glycemic control

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