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


In this clinic-based study, we reported the prevalence of CAM use and individual CAM modalities in a large multi-ethnic CHB cohort, and examined factors that determined CAM usage. A majority of patients used CAM in the past year (71%), ranging from 64% for Chinese to 78% in non-Asian patients. Vitamin and mineral preparations were used most frequently, followed by spiritual healing practices, body-based therapies and herbal medicine. Variables significantly associated with bio-holistic CAM use were female sex, higher socio-economic status, lower serum HBV DNA, and a family history of CHB; ethnicity and migration-related factors were not.

The use of CAM in our study was extensive compared to previous studies in CHB, but was not associated with the use of antiviral treatment or disease severity. Two previous studies in CHB reported that 46% of children used CAM, and 32% of patients in Hong Kong ever used Traditional Chinese Medicine, compared to 19% among Chinese patients in our study.[14,15] Other epidemiological studies in non-CHB chronic liver disease showed substantial variation in CAM use rates (27%-80%).[8,9,11,17] The comparatively high rate of CAM use in this study could be due to the comprehensive definition of CAM, the population under study, and the setting where patients were investigated (tertiary referral centre versus family practice).[18,19]

Prolonged and/or frequent use of presumed noxious CAM compounds can adversely impact clinical disease markers in liver disease, due to herb-drug interactions or influence of cytochrome P450 systems. These findings mainly stem from studies in liver diseases other than CHB.[20–22] In our study, patients were taking mainly 'western style' CAM products (mostly vitamins) and hardly any herbals or supplements with possible beneficial effects for HBV or liver disease. The use of potentially harmful CAM products such as green tea extract or St. John's wort was very low and not associated with liver disease severity, although this should be interpreted cautiously as few participants used these CAM products and no follow-up data was available. We are concerned when patients take a mix of herbs that are difficult to identify, but this did not occur frequently in our population, which was probably biased because all patients visited western style practitioners in a hospital. Alternatively, it might be possible that patients used CAM products which contained hepatotoxins but that they did not consider these as CAM. Nonetheless, this was the largest multi-ethnic clinic-based study in CHB and therefore probably indicative of real world CAM use in CHB in North-America. In order to monitor the (safe) use of CAM, physicians should be encouraged to actively ask about CAM use and specific harmful products, which was currently only done by less than half of the treating physicians.

This study was the first to investigate the influence of ethnicity on CAM modalities in North America, which contains a predominantly immigrant population with CHB. The demographics of Toronto, one of the most multicultural and multiracial cities worldwide where 52% of the population is composed of visible minorities, enabled us to comprehensively evaluate the role of ethnicity in CAM use.[23] CAM use in general differed by ethnicity, specifically for spiritual therapy, yoga, tai chi and homeopathy. The use of spiritual therapy was higher in South-Asian and Black patients compared to other patients. Vitamin and mineral preparation use was surprisingly similar between ethnic groups, possibly because these products have become popular among the population at large in Western countries. Earlier studies on CAM use in ethnic subgroups in Canada combined healthy subjects and patients with chronic conditions, thereby mixing different motives and patterns of use.[17,24] Remarkably, ethnicity and migration-related factors were not associated with oral CAM use after adjustment in multivariable analysis. Other determinants, such as higher socio-economic status, were either much stronger predictors of CAM use or correlated with migration-related factors, so that any effect of ethnicity and migration-related factors might be unobservable, as seen in prior research.[18] The high cost of CAM products likely restricted access to the more affluent patients, regardless of ethnic background. These findings suggest that health care providers of CHB should focus on socio-economic status rather than ethnic or cultural factors when inquiring about CAM use.

The use of CAM is widespread and growing in populations where evidence-based medicine is dominant.[25,26] US adults spent $33.9 billion out-of-pocket annually on CAM visits and products, whereas one in every two European citizens uses CAM, which underlines the breadth of CAM use nowadays.[25,26] Apart from reporting CAM use rates in chronic liver disease patients, it is equally important to gain insight in why patients opt for non-conventional medical therapies. This study showed that most patients used CAM for reasons unrelated to their chronic liver disease, except for herbal medicine. A possible explanation is that the most commonly used herbal products milk thistle (Silybum marianum) and several Traditional Chinese Medicine products have been associated with hepatoprotective effects, while the efficacy of other CAM therapies is less clear.[12,27–30] Additionally, the non-liver related use of CAM could reflect an increasing demand for 'salutogenesis', an approach that focuses on determinants of well-being, rather than on determinants of disease, and is key to the CAM paradigm.[31]

Strong aspects of this study are the inclusion of a large, multi-ethnic cohort of CHB patients who completed an extensive survey on CAM-related factors. Conversely, the inherent recall bias for questionnaires and cross-sectional design restricted us to study long-term consequences of CAM use. Future studies on CAM use in CHB could focus on these long-term effects and associated factors.

In summary, CAM use in this clinic-based population of CHB patients was common and the CAM products that patients used, primarily vitamin and mineral preparations, appeared to be safe. Few patients had used CAM products that were considered to be harmful. CAM use was associated with female sex, higher socio-economic status, lower HBV DNA and a family history of CHB; not with ethnic background, antiviral treatment or liver disease severity. Most treating physicians had not inquired about the use of CAM, neither had most of the patients discussed its use.