Prevalence and Predictors of Complementary and Alternative Medicine Modalities in Patients With Chronic Hepatitis B

Kin Seng Liem; Colina Yim; Thomas D. Ying; Wayel R. Zanjir; Scott Fung; David K. Wong; Hemant Shah; Jordan J. Feld; Bettina E. Hansen; Harry L. A. Janssen


Liver International. 2019;39(8):1418-1427. 

In This Article

Abstract and Introduction


Background & Aims: The use of complementary and alternative medicine (CAM) in patients with chronic hepatitis B (CHB) can interact with antiviral treatment or influence health-seeking behaviour. We aimed to study the use of individual CAM modalities in CHB and explore determinants of use, particularly migration-related, socio-economic and clinical factors.

Methods: A total of 436 CHB outpatients who attended the Toronto Centre for Liver Disease in 2015–2016 were included in this cross-sectional study. Using the comprehensive I-CAM questionnaire and health records, data were collected on socio-demographic and clinical variables and on usage of 16 CAM modalities in the last year.

Results: Sixty percent of patients were male, 74% were Asian and 46% were using antiviral treatment. Three-hundred and nine (71%) patients used CAM. Vitamin/mineral preparations (45% of patients) were most commonly used. Overall CAM use and the specific use of potentially injurious CAM, such as green tea extract (9.2%) and St. John's wort (0.2%), were not associated with liver disease severity. Female sex, family history of CHB, lower serum HBV DNA, and higher socio-economic status were independently associated with bio-holistic CAM use, the clinically most-relevant CAM group (P < 0.05); ethnicity, antiviral therapy use and liver disease severity were not.

Conclusions: CAM use among CHB patients was extensive, especially use of vitamin and mineral preparations, but without direct influence on liver disease severity. Bio-holistic CAM use appeared to be associated with socio-economic status rather than with ethnicity or liver disease severity. Despite the rare use of hepatotoxins, physicians should actively inquire about it.


Chronic hepatitis B (CHB) affects approximately 240 million people worldwide and the associated liver-related morbidity and mortality continue to rise.[1–3] Global migration is changing the epidemiology of CHB, especially in low-endemic regions (North-America, Europe) with a high immigration rate from highly endemic areas.[4,5] These epidemiological shifts increase the ethno-cultural diversity, and could therefore influence the use of and perceptions on conventional Western medicine and on complementary and alternative medicine (CAM).

Patients with chronic diseases increasingly use CAM in addition to, or as a replacement of conventional treatments.[6] CAM is defined as 'a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine'.[7] Examples of CAM include Traditional Chinese Medicine, acupuncture and dietary supplements. The proportion of patients with chronic liver disease who use CAM varies widely from 27% to 80%.[8–11] Patients use CAM both for disease-related symptoms as well as for general well-being.[6] The identification of patterns in CAM use could be of great relevance to health care providers, since CAM products may interact with antiviral treatment or influence the health care-seeking behaviour of patients.[12,13] Insight into CAM use is especially important for an ethnically diverse population such as those with CHB, where ethnic and acculturation factors can enlarge differences in CAM use and clinical outcomes.

The prevalence and predictors of individual CAM modalities in patients with CHB have not been well characterized. Previous studies on CAM use in CHB focused on specific types of CAM, were restricted to subgroups of patients, or evaluated few clinically important determinants.[9,14,15] We evaluated the use of various CAM modalities and its relation to clinical, socio-economic and migration-related factors in a large, multi-ethnic CHB cohort.