Ethnopharmacological survey of plants used for the treatment of diabetes in the town of Sidi Slimane ( Morocco )

The study aimed to screen the antidiabetic plants used by 700 diabetic patients in the town of Sidi Slimane (northwestern Morocco). The results identified 59 species belonging to 28 botanical families, four of which are predominant (Lamiaceae: 9 species; Apiaceae: 7 species; Asteraceae: 5 species; Fabaceae: 4 species). The most used species are: Trigonella foenum-graecum, Oreganum vulgare, Salvia officinalis, Marrubium vulgare and Olea europaea. Similarly, majority of the anti-diabetic recipes are prepared as infusion and decoction. Further, seeds and leaves are the most used parts and are administered orally. These results constitute a database for subsequent studies to experimentally assess the potential of these plants.


INTRODUCTION
Diabetes is a complex disease due to its physiopathological mechanisms, its genetic determinism, as well as the genesis of its complications.It is a heterogeneous group of metabolic diseases whose main feature is a chronic hyperglycemia resulting from a defect in insulin secretion, of its action, or the association of these two anomalies (OMS, 2002).This disease affects more than 285 million people throughout the world, and the number of people provided for diabetic should increase in an outstanding manner to more than 380 million in 2025, thus becoming quickly the epidemic of the 21st century (International Diabetes Federation, 2009).
The OMS estimates that, in 2030, the diabetes will be the seventh leading cause of death in the world (OMS, 2013).
Across all the continents, Africa is the most affected by this disease (Erasto et al., 2005).In Morocco, the diabetes constitutes a major public health problem, indeed, according to a national survey conducted in 2000, the prevalence of this epidemic is located in the vicinity with about 6.6% (Tazi et al., 2000).In addition, according to another study, the number of diabetics exceeds 2.5 million, 7.81% of the Moroccan population, which makes the situation of national public health *Corresponding author.E-mail: majda3amal-85@hotmail.com.
Author(s) agree that this article remain permanently open access under the terms of the Creative Commons Attribution License 4.0 International License eratical in relation to other health and conditions requirements of the population (Ghourri, 2013).More than 1200 species of plants have been used empirically for their presumed glucose lowering activity (Marles and Farnsworth, 1995).The medicinal plants are still a source of medical care in developing countries in the absence of a modern medicinal system (Tabuti et al., 2003).
The objective of this study is to identify the medicinal plants used for the traditional treatment by the diabetic patients in the town of Sidi Slimane which has never been a subject of an ethnobotanical study.

Description of the studied area
Sidi Slimane is a North West city in Morocco (Figure 1), situated between 34° 15 '36' 'N and 5° 55' 12 '' West with a population of 92,989 people in 2014 (Monography of Sidi Slimane City, 2015).It is centrally located in the region of West by its location in a privileged geo-economic space, and very valued by its demographic weight and the importance of its economic apparatus segment in particular agro-industrial.
The region of Sidi Slimane corresponds to a marked oceanic influence, belonging to the semi-arid bioclimatic stage to temperate winter, the high air humidity, prevailing winds from the west.Hydrologically, Sidi Slimane is part of the Sebou catchment.One of its main tributaries (OuedBeht) passes through the agglomeration.The predominant crop of the area is beets, oranges, cotton, vegetable and grain growing (Monography of Sidi Slimane City, 2015).

Ethnopharmacological survey
The survey was conducted among 700 subjects with diabetes in the province of Sidi Slimane (Rabat-Sale-Kenitra's region).The survey was conducted in three different centers: Laghmariyin, Essalam and Wlad Lghazi, where diabetic patients receive consultations and necessary medicines.Patients surveyed were of both sexes and aged between 8 and 98 years old.
For the achievement of the survey, a predetermined questionnaire used includes information on the diabetic patients, the disease, the remedy used and the outcome of therapy.The study investigation lasted for 8 months, from September 2013 to April 2014.

The content of the used questionnaire
The study was conducted with the help of a questionnaire which consists of three parts: 1. Identification: information on the diabetic patient (sex, age, weight, level of education, physical activity and socio-economic level) 2. The disease information (type of diabetes, diabetes discovery circumstances, diabetes complications and family history).3. Traditional remedy: source of supply of medicinal plants, reasons, doses accuracy, plants used, information (parts used, quantity) preparation and cure's dosage, treatment duration and toxic plants knowledge.

Diabetic population's characteristics
The study was carried out on 700 diabetic patients living in the city of Sidi Slimane, the studied population was between 8 and 98 years old, among the two sexes; women were the most affected (72.28%).The results are  shown in Figure 2. The age group most affected by diabetes is between 60 and 70 years old, concerning the weight, more than 29% have a weight between 60 and 70 kg (Figure 3).
The feeding behavior, physical activity, aging and stress are often considered as factors causing obesity which leads to diabetes (King et al., 1998).This assumes the good control of the food supply, a reasonable level of physical activity and adapted policies to the populations at risk, particularly for the people older than 60 years (Fagot-Campagna, 2005).
The study has shown that illiteracy is widespread (60%) among those with diabetes in Sidi Slimane, while 19.42% have a level of primary schooling, 11% medium (college), 6% secondary and only 3.57% have pursued graduate studies.As regards the socio-economic level, only

Disease characteristics
The distribution of the studied population according to the type of diabetes is as follows: 1) 72.57% correspond to type 1; 2) 27.42% correspond to type 2. 87.71 %, of diabetics have discovered the disease by suggestive symptoms, 9.28% by a screening test, and 3% of them have discovered it late.Indeed, more than 65% is hereditary, and less than 18% of patients have presented complications associated with diabetes (Table 1).

Characteristics of the diabetic population according to their use of the phytotherapy
More than 61% of people with diabetes have recourse in herbal medicine to treat diabetes and 38.57% use only the conventional treatment.In previous studies, many authors have shown that the percentage of the use of medicinal plants varies between 52 and 90%, depending on the region or where the investigation has been undertaken (Sekkat, 1987;Magoua, 1991;Nabih, 1992;Bellakhdar, 1997;Ziyyat et al., 1997;Eddouks et al., 2007;Benkhnigue et al., 2011).This strong use of medicinal plants is due to the strong belief of diabetic patients in their efficiency (95.86%), accessibility (2.86%) as well as their low cost (1.29%).
This choice of the use of herbal remedies is based on the advice of other diabetics (54.65%) who have already used them (either from media or from other people), and 45.12% have accounted on the advice of the herbalists while only one person was advised by a doctor in herbal medicine.
With regards to the use of these antidiabetic plants, 54.19% of diabetics use them according to a specific doses, 24.42% in non-specific doses and 21.40% of the use by easy acquisition.These patients have shown great satisfaction in relation to the phytotherapy of more than 58%.In addition to these factors, the contribution of religion in the field of medicinal plants among the plants cited asanti-hyperglycaemic, some are drawn directly from the Koran and religious manuscripts.This is particularly the case of Lawsonia inermis, Trigonella foenum-graecum, Ziziphus lotus, Punica granatum, Myrtus communis, Nigella sativa, Allium sativum, Allium cepa, Olea europaea, Ficus garcia, and Zingiber officinalis (Eddouks et al., 2007).
The richness of the Moroccan gastronomy in plant species is used both as food ingredients and for their therapeutic properties (Eddouks, 2006), as well as nutritional life style.All these factors are considered as the cornerstone in the treatment and prevention of diabetes (Srivastava and Mehdi, 2005).

Knowledge on toxic plants
In this study, more than 74% of the people with diabetes have no information on the toxicity of medicinal plants and only 26% take into account, the illiteracy of a large number of the patients, and the lack of awareness primarily by the indirect harm.Patients using herbal medicine have reported nine plants that have side effects and they are grouped as shown in Table 2 with their side effects.

Medicinal plants used for the treatment of diabetes in Sidi Slimane
The plants used by the diabetics are divided into 59 species, belonging to 28 botanical families and the most represented are the Lamiaceae: 9 species; Apiaceae: 7 species; Asteraceae: 5 species and Fabaceae: 4 species (Figure 4).

Figure 1 .
Figure 1.Map of Morocco showing the surveyed city.

Figure 2 .
Figure 2. Distribution of diabetics by age.

Figure 3 .
Figure 3. Distribution of diabetics based on weight.

Figure 5 .
Figure 5. Part of plants used.

Figure 6 .
Figure 6.Frequency of form of use of anti-diabetic plants.

Table 1 .
Percentage of complications associated with diabetes.

Table 2 .
List of plants with side effects.
T. foenum-graecum: 63 persons; O. vulgare: 38 persons; S. officinalis: 37 persons; M. vulgare: 25 persons and O.europaea: 24 persons) Also, the most used parts are the seeds and the leaves (Figure5).For the mode of preparation, the infusion and decoction

Table 3 .
Inventory of anti-diabetic plants cited in the survey.