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

Patients and Methods

Study Population

Patients with CHB aged 18 years or above who attended the hepatology outpatient clinic of the Toronto Centre for Liver Disease, Canada, between January 1, 2015 and October 31, 2016 were invited to participate in this cross-sectional study. Both new patients and those in follow-up were eligible. The Toronto Centre for Liver Disease is the only specialized Liver Unit in the city of Toronto and comprises a wide variety of immigrants from around the globe. We excluded patients with a history of hepatocellular carcinoma, HIV co-infection, liver decompensation and organ- or bone marrow transplant. The Research Ethics Board of University Health Network approved this study which was performed in accordance with the Good Clinical Practice guidelines and the Declaration of Helsinki. All patients provided written consent.

Data Collection

To address CAM use in patients with CHB, we developed a modified version of the International Complementary and Alternative Medication Questionnaire (I-CAM-Q).[16] The modified I-CAM-Q is a standardized comprehensive survey that comprises demographic, ethnic, socio-economic and clinical data, and use of 16 CAM therapies as classified by the National Center for Complementary and Alternative Medicine. The I-CAM-Q was designed for use across different populations and countries, but has not been validated. Both an English and Mandarin version of the modified I-CAM-Q was available. Patients completed the questionnaire at the time of an outpatient visit with the help of a research coordinator and if needed a translator. Any omissions or ambiguities in responses were followed up during the day of clinic visit or with telephone calls. Ethnicity-related questions involved country of birth, ethnicity, primary language, immigrant status and time since immigration. Ethnicity was categorized into five groups: Chinese (China, Hong Kong, Taiwan), South-East Asian (Philippines, Korea, Vietnam, Thailand, Cambodia, Laos, Indonesia, Malaysia), South-Asian (India, Pakistan, Afghanistan, Bangladesh, Tibet), Caucasian (Europe, Russia, Turkey, Middle-East, North-Africa, Hispanic/Latino) and Black (Africa, Haiti, Jamaica). Socio-economic information included annual household income over the last 12 months, highest level of education, employment status and private insurance coverage. Clinical data (body height and weight, duration of hepatitis B virus (HBV) infection, serum ALT, serum HBV DNA, HBeAg status, cirrhosis (defined as Metavir F4/Ishak stage 6 on liver biopsy, or radiographic evidence of cirrhosis), current and past CHB treatment, duration of CHB treatment, as well as family history of CHB and/or hepatocellular carcinoma were retrieved from patient medical records and the questionnaire.

CAM therapies have been categorized by the National Center for Complementary and Alternative Medicine of the National Institutes of Health.[7] We obtained information on the following CAM domains and modalities from the survey: holistic therapies (homeopathy, acupuncture, naturopathy), biologically-based practices (herbal products, vitamin and mineral preparations, dietary supplements), manipulative and body-based therapies (chiropractic, massage, manipulation), mind–body medicine (meditation, spiritual therapy, visualization/guided imagery, health prayers, attendance of a traditional healing ceremony, qi gong, tai chi, yoga). For every type of CAM, patients reported visits to CAM providers, the use of CAM products, the frequency and duration of use, the primary aim (treatment of acute or chronic symptoms of CHB, general well-being, other reason), the efficacy of CAM practice, (reasons for) non-disclosure and physician inquiry about of CAM use.

Statistical Analysis

Baseline characteristics are reported in means ± standard deviations (SD) for continuous variables, or frequency (percentage) for categorical variables. Differences in baseline characteristics and outcomes were analysed using chi-squared test, Fisher's exact test, Student's t test or Mann-Whitney test, where appropriate. Current CAM use was defined as annual or more frequent use of at least one of the CAM modalities. To evaluate whether ethnicity, antiviral treatment and hepatitis activity were associated with use of CAM, predictors that were univariably associated with CAM use in logistic regression (p-value < 0.10) were analysed in multivariable logistic regression. For this analysis, the clinically most relevant CAM groups (holistic and biologically-based therapies) were included. These bio-holistic CAM therapies were selected for further analysis because of potentially relevant clinical interactions. In addition there was insufficient statistical power to include other CAM modalities. Covariates included age, sex, ethnicity, duration of CHB, current antiviral treatment, previous use of pegylated (PEG-) interferon, previous use of nucleos(t)ide analogues (NA), cirrhosis, serum ALT level, serum HBV DNA level, HBeAg status, body mass index (BMI), family history of CHB and/or liver cancer, time since immigration, immigrant status, highest level of education, employment status, annual income and private drug plan coverage. All p-values were two-sided with a significance level of 0.05. Analyses were performed in SPSS (v. 22.0, Chicago, IL).