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


Patient Characteristics

A total of 600 patients were approached in the inclusion period, of whom 436 (73%) patients completed the survey. Patients were excluded due to the following: HBsAg negative (n = 7), relevant co-morbidity (n = 7), acute HBV (n = 2), or refusal to participate (n = 148). Sociodemographic and clinical characteristics of enrolled patients according to CAM use are shown in Table 1. The mean (SD) age was 49 (14) years, 263 (60%) patients were male, and 201 (46%) currently used antiviral treatment for CHB. Two hundred eight (48%) patients were Chinese, 86 (20%) South-East Asian, 28 (6.4%) South-Asian, 72 (17%) Caucasian, 39 (8.9%) Black and 3 (0.7%) patients had more than one race/ethnicity. Two-hundred and nine (48%) patients born abroad had lived for 20 or more years in Canada. Two-hundred and sixty-four (61%) patients had finished college or higher education and 235 (54%) did not have any private insurance plan. Fifteen percent was HBeAg positive, the mean ALT was 1.5 (0.3) log IU/mL, median HBV DNA 1.8 (0.0-3.6) log IU/mL, and 65 (15%) patients were cirrhotic. Two-hundred and three (47%) patients had a family history of CHB.

Several characteristics were significantly different between CAM users and CAM non-users. Notably, CAM users were predominantly female, South-Asian or Black, had a higher socio-economic status, and more often a family history of CHB. Other baseline characteristics were comparable between CAM users and CAM non-users.

Patterns of CAM use

Three hundred nine (71%) patients had used CAM at least once during the past 12 months, and two hundred fifty-six (59%) patients had used CAM regularly (at least monthly; Figure 1). Biologically based (51%) and mind–body therapies (35%) were the most frequently utilized CAM domains. Within these domains, vitamin and mineral preparations (45%), spiritual practices (29%), and dietary supplements (21%) were the most common CAM modalities. The use of body-based therapies (24%) was moderate and the use of holistic practices (8.9%) was low.

Figure 1.

Use of CAM modalities in the last 12 mo in 436 patients with CHB

CAM use was significantly different among different ethnicities (64% in Chinese, 72% in Caucasians, 76% in SE-Asians, 79% in South-Asian, and 87% in Blacks; P = 0.03 (Table 1 and Table S1). Specifically, mind-body medicine was practised more often by South-Asian (54%) and Black patients (77%) than other ethnic groups (22%; P < 0.005). Homeopathy (2.8%) and naturopathy (1.4%) were more often used by Caucasian than other groups (P = 0.03). The overall use of vitamin and mineral preparations (45%) and herbal product use (16%) did not differ significantly among ethnic groups. Vitamin and mineral supplements predominantly comprised of vitamin D (39%), multivitamins (38%), calcium (26%), vitamin C (19%), and omega-3 fatty acid (19%). Ginger extract (34%), milk thistle (15%) and ginseng (5.9%) were the most commonly used herbal preparations.

The use of CAM products with a reported hepatoprotective or hepatitis B infection-altering effect (milk thistle and ginger extract) was very low (3%) and was not related to subjects' liver disease severity, as was reflected by no association with serum ALT, HBV DNA or presence of cirrhosis (P > 0.05). The use of green tea extract (9.2%) and St. John's wort (0.2%), the only known potentially harmful CAM products in this study, was not associated with liver disease severity (P > 0.05).

Attitudes Towards CAM use

The main reason to use herbal products was to improve general well-being (63%; Table 2). Thirty-two percent of patients used herbal products for liver-related symptoms, compared to 2.6% of vitamin and mineral product users (P < 0.005). Homeopathy and spiritual therapies were rated predominantly as very helpful, whereas most other CAM therapies were considered helpful. A quarter of patients rated vitamin/mineral (24%) and other supplements (25%) as not helpful at all. The majority of patients (87%) started CAM therapy before they were diagnosed with CHB and had been using it for at least 5 years, especially acupuncture (71%), visualization (57%) and herbal medicine (67%).

Forty-three percent of physicians had actively inquired about CAM use (Supplementary Table 1). Doctors had inquired about CAM use less often in Caucasian patients (33%) than in Chinese patients (46%; P = 0.06). Fifty-two percent of patients had not informed their physicians about CAM use, ranging from 46% (Black patients) to 64% (South-Asian patients), and this did not differ between ethnic groups. The main reasons for patients not to disclose CAM use were: not considered important to inform treating physician, non-liver related CAM use, not inquired by physician, anticipated physician disinterest or disapproval, and already informed general practitioner or other treating physician.

Determinants of Bio-holistic CAM use

Determinants for the use of the clinically most relevant CAM group, (bio-holistic CAM, were studied with logistic regression (Table 3). The bio-holistic CAM therapies were selected because of possible clinical interactions and limited statistical power to study other CAM products. Female sex (OR for female versus male: 2.18; 95%CI: 1.35-3.59; P < 0.005), higher education level (Master's degree vs ≤ High school, OR: 2.95; 1.40-6.20; P < 0.005), employment status (OR for retired vs employed: 5.22; 2.72-10.03; P < 0.005), higher private drug plan coverage (80%-100% vs. none, OR: 2.07; 1,98-3,94; P = 0.02), lower HBV DNA (OR: 0.89; 0.81-0.98; P = 0.02) and a family history of CHB (OR: 1.65; 95%CI: 1.07-2.55; P = 0.03) were independently associated with use of bio-holistic CAM modalities. Age, ethnicity, immigrant status, time since immigration, and primary language were not associated.