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Case ReportDietary cactus reduces blood glucose levels in a Hispanic man
David Faldmo, MPAS, PA-C; Michelle Stephan, RN; Steven T. Boyd, PharmD, CDM, CDE; David M. Scott, MPH, PhDMr. Faldmo practices at Siouxland Community Health Center, Sioux City, Iowa. Ms. Stephan is the Quality Director at the Siouxland Community Health Center. Dr. Boyd is an Assistant Professor at Creighton University and a clinical pharmacist at the Omaha Veterans Affairs Medical Center, Omaha, Neb. Dr. Scott is Associate Professor, Department of Pharmacy Practice, College of Pharmacy, North Dakota State University, Fargo. The authors have indicated no relationships to disclose relating to the content of this article.The patient mentioned that, at the suggestion of family members from Mexico, he had started eating cactus daily to control his diabetes immediately after receiving the diagnosis. CaseA 53-year-old Hispanic man presented to a community health center complaining of excessive thirst and frequent urination for the past 3 weeks. He was otherwise feeling fine, but he was worried about having diabetes. He was familiar with some of the symptoms of this disease because his mother had it. The patient had no other complaints. Other than an appendectomy in 1971, his medical history was negative for any other surgeries, hospitalizations, or serious injuries or accidents. He reported being a social drinker and occasionally smoking cigarettes. He described a diet primarily of authentic Hispanic foods (tacos, tortillas, rice, etc.), with diet soda and cookies consumed on a regular basis. Except for renal cancer in his father, the family history was unremarkable, with no one besides the mother having diabetes. The physical exam was normal. Laboratory values were as follows: urine dipstick, 1,000+ glucose; capillary glucose, 237 mg/dL; AIC, 12.4%; total cholesterol (TC), 233 mg/dL; HDL cholesterol (HDL-C), 37 mg/dL; LDL cholesterol (LDL-C), 136 mg/dL; and triglycerides, 298 mg/dL. Extended-release glipizide (Glucotrol XL), 5 mg once daily, was prescribed, some brief diabetes education was provided, and the patient scheduled a follow-up in 2 weeks. At the return visit, he was feeling fine and mentioned that his polydipsia and polyuria had resolved. The patient received a glucometer with instructions on how to use it for blood glucose self-monitoring. He was advised to check his blood glucose twice a day and was scheduled to return in 3 weeks. At that follow-up visit, he complained of having had hypoglycemic symptoms and said he had stopped taking the glipizide. Extended-release metformin (Glucophage XR), 500 mg once daily, was prescribed, and the patient was instructed to monitor his blood glucose levels closely. Three weeks later, he was doing well on the metformin; the self-monitoring log revealed glucose levels in the low 100s (mg/dL), and the patient denied any hypoglycemic episodes. The patient missed his 3-month follow-up appointment but returned 1 month after that for laboratory testing. Results were as follows: A1C, 6.6%; TC, 214 mg/dL; HDL-C, 37 mg/dL; and LDL-C, 123 mg/dL. About 2 weeks later, he, on his own, discontinued metformin and began to control his diabetes through diet only. He reported that his exercise routine consisted mainly of walking and that this pattern had not changed since diagnosis. Three months later, at the next follow-up visit, the patient denied any complaints, and his blood glucose level was in an acceptable range. Laboratory results included A1C, 6.0%; TC, 191 mg/dL; HDL-C, 37 mg/dL; and LDL-C, 112 mg/dL. At this visit, he mentioned that he had started eating cactus daily to control his diabetes immediately after receiving the diagnosis. He had not changed his diet other than to add the cactus. Family members from Mexico had encouraged him to do this since they, like other members of this ethnic group, believed cactus to be a good way to control diabetes. The patient had been going to a local Mexican grocery store to purchase heads of the cactus Opuntia streptacantha (see Figure 1). In the mornings, he blended pieces of cactus to make a shake; later in the day, he made a salad of diced cactus. He was convinced that the cactus was controlling his disease. He was advised to continue doing whatever he was doing through lifestyle and diet, as it appeared to be working well. Fifteen months after the initial diagnosis, the patient was seen in the office for a follow-up visit. He said that he had grown tired of eating cactus and had eliminated it from his diet. His A1C level was 8.6% at this appointment (see Table 1).
DiscussionThe behavior of this patient is consistent with that of other Hispanic patients seen at the Siouxland Community Health Center in regard to common use of O streptacantha and the observed beneficial results. At the health center, two other diabetic patients were also utilizing cactus in combination with prescription medications. Over a 6-month period, one patient's A1C decreased from 10.4% to 6.7% and another's went from 13.5% to 5.4%. All these patients added cactus to their diet, but none of the three made any other known lifestyle changes, such as adopting an exercise program or otherwise altering diet. None of the patients received extensive nutritional education. Long-term studies attempting to show sustained reductions in A1C with cactus use have not been performed. Only two short-term, controlled trials have been published reporting improvements in fasting glucose and insulin levels in patients with type 2 diabetes who ate cactus.1,2 Both trials compared cactus with placebos. The high soluble fiber and pectin content of cactus was thought to account for its effect on glucose and insulin levels. According to the 2000 census, Latinos recently became the number-one minority in the United States at 12.5% of the population, or almost 40 million people.3 According to a recent survey of 82 Latino patients in the Los Angles region, 92% reported using herbal products for diabetes control.4 Compared to whites, Mexican-Americans have a higher incidence of diabetes, with the disease affecting 24% of Mexican-Americans aged 45 to 74 years. This patient population has traditionally used medicinal plants to control a variety of illnesses, including diabetes. In Mexico, the opuntia cactus is the favorite plant remedy among many patients (73.1% in one study5) and is considered a "traditional indigenous" treatment for type 2 diabetes.5 As more patients turn to complementary and alternative therapies and the Latino population continues to increase in the United States, clinicians will be faced with more such nontraditional approaches. It is important to ask patients whether they use these approaches, keeping in mind that many do not view eating cactus as taking a medicine. They eat it as part of their regular diet, or they eat it to "treat" symptoms of diabetes as needed. The authors believe that to maintain steady blood glucose control, patients should eat cactus consistently and report the amount and type of cactus use to their health care provider. Good communication will help maintain reduced blood glucose levels. This case report suggests that the use of O streptacantha may help control blood glucose levels in patients with diabetes. Further research is needed using a controlled-study design and a more diverse patient population to assess the safety and effectiveness of this alternative therapy for long-term treatment of diabetes. REFERENCES 1. Yeh G, Eisenberg DM, Kaptchuk TJ, Phillips RS. Systematic review of herbs and dietary supplements for glycemic control in diabetes. Diabetes Care. 2003;26: 1277-1294. 2. Frati Munari AC, Vera Lastra O, Ariza Andraca CR. Evaluation of nopal capsules in diabetes mellitus [in Spanish]. Gac Med Mex. 1992;128:431-436. 3. US Census Bureau. American Community Survey 2003 Data Profile. United States. Table 1. General demographic characteristics. Available at: http://www.census.gov/acs/www/Products/Profiles/Single/2003/ACS/Tabular/010/01000US1.htm . Accessed August 26, 2004. 4. Shapiro K, Gong WC. Use of herbal products for diabetes by Latinos. J Am Pharm Assoc (Wash). March/April 2002;42:278,279. 5. Argaez-Lopez N, Wacher NH, Kumate-Rodriguez J, et al. The use of complementary and alternative medicine therapies in type 2 diabetic patients in Mexico. Diabetes Care. 2003;26:2470,2471.
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