LITERATURE REVIEW

2.2.1 Overview of Type 2 Diabetes

Type 2 diabetes mellitus is a chronic condition that affects the way the body processes blood
sugar (glucose). It is characterised by insulin resistance and relative insulin deficiency, leading to
hyperglycaemia. Type 2 diabetes is the most common form of diabetes, accounting for
approximately 90–95% of all cases (1). It typically develops in adults over the age of 45, but it is
increasingly being diagnosed in younger age groups, including children, adolescents, and young
adults (2). Several risk factors contribute to the development of type 2 diabetes, including
genetics, obesity, physical inactivity, and poor dietary habits (3).

The prevalence of type 2 diabetes has been steadily rising worldwide, posing significant public
health challenges. According to the International Diabetes Federation (IDF), in 2019,
approximately 463 million adults were living with diabetes globally, and this number is
projected to rise to 700 million by 2045 (4). Type 2 diabetes is associated with a range of
complications, including cardiovascular disease, kidney disease, nerve damage, and eye
problems (5). Early diagnosis, lifestyle modifications, and appropriate medical management are
crucial in preventing or delaying the onset of complications and improving the quality of life for
individuals with type 2 diabetes (6).

2.2.2 Symptoms of Type 2 Diabetes

The symptoms of type 2 diabetes can develop gradually and may be subtle, making it
challenging to detect in the early stages. Common symptoms include:

Increased thirst and frequent urination

Excessive hunger

Unexplained weight loss

Fatigue

Blurred vision

Slow-healing sores or frequent infections

Areas of darkened skin, usually in the armpits and neck

These symptoms occur due to the body's inability to effectively use insulin, leading to elevated
blood sugar levels (7). It is important to recognise these signs and seek medical attention for
proper diagnosis and management.
2.2.3 Causes of Type 2 Diabetes

The development of type 2 diabetes is influenced by a combination of genetic, lifestyle, and

environmental factors. The primary causes include:

Insulin resistance: The body's cells become resistant to the effects of insulin, resulting in
elevated blood sugar levels.

Impaired insulin production: The pancreas may not produce enough insulin to compensate for
the resistance, leading to hyperglycaemia.

Obesity: Excess body fat, especially abdominal fat, contributes to insulin resistance (8).

Sedentary lifestyle: Lack of physical activity reduces the body's ability to use insulin effectively.

Unhealthy diet: High intake of processed foods, sugary beverages, and saturated fats increases
the risk of developing type 2 diabetes (9).

Genetics also play a role, as individuals with a family history of diabetes are at a higher risk.
Additionally, certain ethnic groups, such as African, Hispanic, Asian, and Indigenous
populations, have a higher predisposition to type 2 diabetes (10).

2.2.4 Insulin and Glucose Regulation

Insulin is a hormone produced by the pancreas that plays a crucial role in regulating blood sugar
levels. After consuming food, carbohydrates are broken down into glucose, which enters the
bloodstream. In response, the pancreas releases insulin, which facilitates the uptake of glucose
into cells for energy or storage (11). In type 2 diabetes, this process is disrupted due to insulin
resistance and impaired insulin secretion. As a result, glucose accumulates in the bloodstream,
leading to hyperglycaemia. Over time, the pancreas may struggle to maintain adequate insulin
production, exacerbating the condition. Proper insulin and glucose regulation are essential for
maintaining metabolic balance and preventing complications associated with type 2 diabetes
(12).

2.2.5 Risk Factors of Type 2 Diabetes

Several risk factors increase the likelihood of developing type 2 diabetes. These risk factors can
be categorised into modifiable and non-modifiable factors:

Modifiable risk factors:

Overweight and obesity, particularly abdominal obesity

Physical inactivity
Unhealthy diet (high in sugars and fats)

Smoking

High blood pressure and abnormal cholesterol levels

Non-modifiable risk factors:

Age (risk increases with age, especially after 45)

Family history of diabetes

Ethnicity (higher risk in African, Hispanic, Asian, and Indigenous populations)

History of gestational diabetes or polycystic ovary syndrome (PCOS)

Understanding these risk factors is essential for early identification and prevention strategies
aimed at reducing the incidence of type 2 diabetes (13).

2.2.6 Diagnosis and Tests for Type 2 Diabetes

Diagnosing type 2 diabetes involves various blood tests to measure blood glucose levels. The
main diagnostic tests include:

Fasting Blood Glucose Test: Measures blood sugar after an overnight fast. A level of 126 mg/dL
(7.0 mmol/L) or higher indicates diabetes.

Oral Glucose Tolerance Test (OGTT): Measures blood sugar before and two hours after
consuming a sugary drink. A two-hour value of 200 mg/dL (11.1 mmol/L) or higher confirms
diabetes.

HbA1c Test (Glycated Hemoglobin): Reflects average blood glucose levels over the past 2–3
months. An HbA1c level of 6.5% or higher suggests diabetes (14).

These tests help healthcare providers assess glucose control and determine the appropriate
treatment plan.

2.2.7 Complications of Type 2 Diabetes

Type 2 diabetes can lead to a range of complications if not properly managed. These
complications affect various organs and systems in the body and include:

Cardiovascular disease: Increased risk of heart disease, stroke, and hypertension

Neuropathy: Nerve damage, particularly in the legs and feet, leading to pain, tingling, and loss
of sensation

Nephropathy: Kidney damage that can progress to kidney failure

Retinopathy: Eye problems, including damage to the blood vessels in the retina, potentially
causing blindness

Foot problems: Poor circulation and nerve damage increase the risk of foot ulcers and
infections, sometimes leading to amputation

Skin conditions: Higher susceptibility to bacterial and fungal infections

Hearing impairment: Increased risk of hearing loss

Alzheimer’s disease: Potential link between type 2 diabetes and an increased risk of dementia
(15)

Proper management of blood sugar levels, blood pressure, and cholesterol, along with regular
medical check-ups, can help prevent or delay the onset of these complications (16).

2.2.8 Prevention of Type 2 Diabetes

Preventing type 2 diabetes involves adopting a healthy lifestyle and addressing modifiable risk
factors. Key prevention strategies include:

Healthy Eating: Consuming a balanced diet rich in whole grains, fruits, vegetables, lean proteins,
and healthy fats

Regular Physical Activity: Engaging in at least 150 minutes of moderate-intensity exercise per
week

Weight Management: Achieving and maintaining a healthy weight to reduce insulin resistance

Avoiding Tobacco Use: Smoking cessation lowers the risk of diabetes and cardiovascular
complications

Limiting Alcohol Consumption: Moderation in alcohol intake supports overall health

Regular Health Screenings: Monitoring blood glucose levels, blood pressure, and cholesterol
helps detect early signs of diabetes and related conditions (17)

Implementing these preventive measures can significantly lower the risk of developing type 2
diabetes and improve overall well-being.
2.2.9. The use of traditional medicine

Herbal medicine is the use of plants and plant extracts to treat disease. Many modern drugs
were originally extracted from plant sources, even if they’re now made synthetically. Whereas
conventional medicine now tries to use only the active ingredient of a plant, herbal remedies
use the whole plant (18).

Herbalists argue that the mixture of chemicals in the whole plant work together to give a better
effect (called synergy) than a single active ingredient (19).

Throughout history, many cultures have relied heavily on plants and herbs for medicinal
purposes. Modern medicine is now looking at how these traditional sources can be used to
treat and manage diabetes either along with conventional medications or on their own (20).
The source and purity of an herb is crucial for effectiveness and to minimize any possible side
effects. Professional guidance is always advised when using herbal remedies (21).

In diabetes, the body either does not produce enough insulin or produces insulin that it does
not use effectively.

Herbs and supplements cannot cure diabetes and cannot be a standalone treatment. However,
some, combined with conventional treatment, may relieve diabetes symptoms and reduce the
risk of complications (22).

1. Aloe vera

Aloe vera is a common plant with various uses. Many people are aware of its benefits for the
skin, but it may have others, including slowing the progress of type 2 diabetes (23).

Another 2020 review looked into animal cell studies and found other evidence to support
earlier findings, concluding that aloe vera might help:

Increase insulin levels, boost the health and number of related cells in the pancreas, known as
islets

Protect against diabetic kidney disease, depression, and anxiety by reducing oxidative stress

Boost eye health, as seen in one rodent study (24)

These results appear promising, but ensuring that aloe vera is safe and effective for people with
diabetes will require further human research.

2. Cinnamon
Cinnamon is a fragrant spice that comes from the bark of a tree. It is a popular ingredient in
sweets and baked goods, as well as some savory dishes.

This spice may add sweetness to a dish, limiting the need for sugar. It is popular among people
with type 2 diabetes for this reason alone, but it may also have other benefits.

A 2016 review found evidence from human studies that cinnamon may improve levels of fasting
plasma glucose (FPG) or hemoglobin A1c (HbA1c) (25). However, most participants continued
their hypoglycemic medications during the study.

In another review, researchers concluded that a cinnamon supplement’s effect on lowering

lipids or reducing fat mass was inconclusive and help reduce fasting blood glucose and insulin
resistance in people with prediabetes and type 2 diabetes (26).

3. Bitter melon

Momordica charantia, or bitter melon, is a medicinal fruit. People cook it and enjoy it in many
dishes. Practitioners of traditional Chinese and Indian medicines have used bitter melon for
centuries. More recently, researchers have been looking into its properties.

There is some evidence that bitter melon may help manage diabetes. In a 2020 study, 90
participants took either bitter melon extract or a placebo. Those who took the extract had
lower fasting blood glucose levels after 12 weeks but no difference in HbA1c levels (27).

4. Ginger

Ginger is another herb that people have used for thousands of years in traditional medicines.
People often use ginger to help treat digestive and inflammatory issues. In 2015, a review found
that it could also help treat diabetes. The researchers concluded that ginger lowered blood
sugar levels but not blood insulin levels. As a result, they suggested that ginger might reduce
insulin resistance in people with type 2 diabetes (28).

People can take ginger: by adding it powdered or fresh and thinly sliced to raw or cooked
dishes, brewed into tea, as a supplement in capsule form, by drinking it in ginger ale.

5. Milk thistle

Silymarin, the extract from milk thistle that scientists have paid most attention to, is a
compound with antioxidant and anti-inflammatory properties. These may make milk thistle a
useful herb for people with diabetes (29).
Many results of investigations into the effects of silymarin have been promising, but not
promising enough for experts to recommend the herb or its extract alone for diabetes care,
according to one review from 2016 (30).

6. Gymnema

Gymnema sylvestre is an herb that comes from India. Its name means “sugar destroyer.”
People widely use it in Ayurvedic medicine.

One 2019 review of cell and rodent studies reported gymnema could:

Reduce blood glucose levels

Increase antioxidants

Decrease stress

Lower cholesterol

Decrease body weight and inhibit fat accumulation (31)

2.2.10. Conventional treatment

Conventional treatment, also known as mainstream or Western medicine, refers to medical

practices and treatments that are widely accepted and used by healthcare professionals. These
treatments are based on scientific evidence and are typically provided in hospitals, clinics, and
medical offices (32).

It's worth noting that conventional treatment may not be the only approach to healthcare, and
some individuals may choose to use alternative or complementary therapies in addition to or
instead of conventional treatment.

A variety of medications are available to assist you in managing and treating diabetes. Since
everybody is different, the care you receive can be tailored to your specific needs.

According to the American Diabetes Association, some medicines for Type 2 Diabetes include:

1. Sulfonylureas – Stimulate insulin release from the pancreas, like Glibenclamide (Glyburide),
which stimulates insulin release, improving glycemic control.

2. Biguanides – Decrease glucose production in the liver and increase insulin sensitivity, like
Metformin: first-line treatment for type 2 diabetes, improves insulin sensitivity and reduces
glucose production.
3. Alpha-glucosidase Inhibitors – Delay carbohydrate absorption in the gut, like Acarbose:
delays carbohydrate absorption, reducing postprandial blood glucose spikes.

4. Thiazolidinediones – Increase insulin sensitivity, like Pioglitazone: improves insulin sensitivity,

but may have increased risk of bladder cancer and heart failure.

5. Insulin – Essential for type 1 diabetes management and sometimes used in type 2 diabetes,
including various formulations: rapid-acting, short-acting, intermediate-acting, and long-acting
insulin analogs such as insulin aspart and insulin glargine (33).

The Barriers to Diagnosis and Treatment of Diabetes

According to the Canadian Association of Emergency Physicians Research Consortium (2015),

the prevalence of diabetes mellitus among the population represents a health crisis.
Researchers and patients have identified barriers to prompt diagnosis and treatment of
diabetes. These barriers include poverty, co-morbidities, cultural indifference, and lack of
healthcare resources (34).

Barriers identified by participants include access to transportation, educational material,

traditional care and medicine, and diagnostic services. Suggestions for possible solutions to
barriers were grouped into three categories: education, overcoming systemic barriers, and
cultural relevance (35).

2.3 Theoretical Framework

This study was formed by the Health Belief Model.

2.3.1 Health Belief Model

Originally developed in the 1950s and proposed by social psychologists Godfrey Hochbaum,
Irwin Rosenstock, and later expanded by Rosenstock and Kirscht, the Health Belief Model is
based on the theory that the willingness to change health behaviors primarily comes from
health perceptions. According to this model, beliefs about health and health conditions play a
significant role in determining health-related behavior (36). The theory is composed of six
constructs: perceived severity, perceived susceptibility, perceived benefits, perceived barriers,
cues to action, and self-efficacy.

Perceived Severity refers to the probability that a person will change their health behavior to
avoid a consequence, depending on how serious they believe the consequences will be.
Although severity can influence outcomes, many studies have shown it is actually the least
powerful predictor of preventive behaviors.
Perceived Susceptibility implies that individuals are unlikely to change health behaviors unless
they believe they are at risk.

Perceived Benefits focus on what individuals stand to gain. People are less inclined to abandon
behaviors they enjoy unless there is a clearly perceived benefit, such as believing that healthy
eating and regular exercise can prevent diabetes.

Perceived Barriers involve the challenges that discourage people from changing behavior, suh
as effort, cost, discomfort, and time constraints.

Cues to Action are external prompts that motivate individuals to take health actions. These
could include seeing someone else suffer from complications, or being advised by a healthcare
professional.

Self-Efficacy, which was added to the model in 1988, refers to one’s belief in their own ability to
perform a health-related behavior successfully (36).

This theory is relevant to this study for the following reasons: Firstly, when diabetic patients in
Bamenda III Health District understand the severity of diabetes, they are more likely to take
medication to manage it. Secondly, the model emphasizes creating awareness among diabetic
patients in this district about the importance of taking their medication regularly, as this
increases their perception of its effectiveness. Thirdly, observing the consequences of non-
adherence in others, such as death, can serve as cues to action that motivate patients to
engage in their own treatment.

2.4 Empirical Review

2.4.1 Effectiveness of Herbal Medication Used in the Management of Type 2 Diabetes

Alzahrani et al. carried out a study titled "Perception of herbal use in treating diabetes among
patients attending specialized polyclinics of National Guard Health Affairs, Jeddah," which
aimed at assessing the effectiveness of herbal medicine in the management of type 2 diabetes.
The study employed a quantitative descriptive cross-sectional design and included 196
purposively selected type 2 diabetic patients. Using a structured questionnaire and analyzing
data through SPSS version 20.0, the findings revealed that out of 196 participants, 117 had used
herbal medicine and confirmed it to be effective and beneficial to their health and wellbeing.
The study also found that herbal medicines were commonly used among these patients, with
only 18% reporting complete dependence on conventional medicine. Based on these findings, it
was recommended that patients should be encouraged to take type 2 diabetes herbal
medicines of proven effectiveness alongside conventional medicines (37).
Similarly, Aljawharah et al. (2023) conducted a study titled "Assessing the effectiveness of
herbal medicine in the management of type 2 Diabetes in India," with the main objective of
investigating the effectiveness of herbal treatments. Using a cross-sectional study design, a
sample of 289 type 2 diabetic patients was selected through purposive and convenience
sampling techniques. A structured questionnaire was used for data collection, and analysis was
conducted using SPSS version 26. Findings revealed that 203 participants used herbal medicine
and expressed satisfaction with it in managing type 2 diabetes. The study highlighted that there
has been renewed attention toward traditional medicine globally, with 80% of Africa's
population relying on traditional herbal remedies. It was therefore recommended that the
public should be educated on the possible use of herbal medicine (38).

2.4.2 The Type of Herbal Medications Commonly Used by Individuals with Type 2 Diabetes

Sana Jaher et al. (2013) in Libya carried out a study titled "Choice of herbal drug used in
management of type 2 Diabetes," aimed at exploring the commonly used traditional medicines
in managing type 2 diabetes. The cross-sectional study involved a purposive sample of 523
participants, with data collected using self-report questionnaires and analyzed using SPSS
version 22. The study found that a large proportion of participants reported using a variety of
herbal medicines for managing type 2 diabetes, with a total of 77 traditional medicine items
identified. These included herbs such as roots, leaves, flowers, bark, berries, and seeds. The
most common ones mentioned were Devil’s claw, kava, Echinacea, ginseng, ginger, St. John’s
wort, black and blue cohosh, red raspberry leaf, and castor oil. The study concluded that herbal
remedies have long been used for health conditions globally and recommended that clinicians
should ask patients about traditional medicine use during consultations, as some herbs may
have hypoglycemic effects that interact with conventional medicines (39).

2.4.3 Knowledge and Practices of Individuals with Type 2 Diabetes Regarding the Use of
Herbal Medications Alongside Conventional

Ravi Raja et al. (2011) conducted a study titled "Assessing knowledge and practice of use of
herbal and conventional medicine in management of type 2 Diabetes" in Karachi, aiming to
assess patients’ knowledge and practices regarding the combined use of herbal and
conventional medicine. Using an observational, prospective cross-sectional study design, a
purposive sample of 261 diabetic patients (102 females and 159 males) was selected. Data were
collected using questionnaires and analyzed using SPSS version 16.0. The study showed that
most participants had good knowledge of using herbal medicine alongside conventional
medicine and were proactive in buying drugs and adopting preventive measures. It was also
noted that the practice of using herbal medicine, either alone or in combination, is widespread
especially in low-resource settings due to its natural origin and perceived lower side effects. The
authors recommended that awareness programs should be implemented to ensure everyone is
informed (40).

In another study carried out by Lydia Aziato et al. (2016) in Ghana titled "Factors associated
with knowledge and practice on use of herbal medicine and conventional medicine in
management of type 2 Diabetes," the aim was to examine factors that hinder adherence to
both herbal and conventional treatments. A cross-sectional design was used with a purposive
sample of 16 participants (9 men and 7 women), and data were collected through face-to-face
interviews. NVivo software version 10 was used for data analysis. The findings showed that
most participants had little knowledge of herbal and conventional medicine, and many did not
practice the use of both treatments. The reasons included illiteracy, poverty, cultural beliefs,
and long distances to drug access points. The study recommended that healthcare systems
should include herbal medicine options to accommodate patients’ preferences and that more
education should be provided on diabetes treatment and prevention (41).
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