Prevalence and patterns of complementary and alternative medicine use in patients with chronic liver disease

INTRODUCTION

Complementary and alternative medicine (CAM) refers to a broad range of healthcare practices that are not part of conventional medicine, such as herbal remedies, acupuncture, meditation, yoga, and dietary supplements. These treatments are often used alongside or in place of traditional therapies and are rooted in cultural beliefs or holistic approaches to wellness. CAM's popularity has increased significantly in recent years.^[1]

Before the rise of modern biomedicine in the 1800s, traditional medical practices like herbal remedies were common, with health viewed holistically. The advancement of medical science shifted focus to biomedicine, sidelining traditional methods in the West. However, in the 1960s and 70s, interest in CAM resurfaced, driven by cultural shifts toward holistic and Eastern practices.^[2]

In India, CAM practices are deeply ingrained in cultural traditions and widely used. Surveys such as the NSSO and NFHS show significant reliance on indigenous medicine systems like Ayurveda, Yoga, Unani, Siddha, and Homeopathy (AYUSH), with around 6.9% to 7.2% of households utilizing them. CAM's popularity is influenced by factors such as accessibility, affordability, cultural beliefs, and positive past experiences. People often turn to CAM for chronic conditions, dissatisfaction with conventional treatments, and recommendations from trusted sources.^[3]

The use of CAM is widespread among chronic liver disease (CLD) patients, often driven by cultural beliefs, dissatisfaction with conventional treatments, or the perceived naturalness and safety of CAM therapies. However, while the appeal of CAM remains strong, various studies have shown that many CAM products—especially herbal supplements, powders, and tablets—can be hepatotoxic, leading to further deterioration of liver function.

In India, the situation is further complicated by the easy availability of inexpensive CAM products prescribed by unauthorized or self-proclaimed practitioners. Despite the potential risks, the extent and patterns of CAM use among CLD patients are not well documented. There is a pressing need to systematically assess the prevalence, types, usage, and associated factors in this vulnerable group. Understanding these elements is essential to guide patient education, inform regulatory measures, and incorporate screening for CAM use into routine clinical practice for CLD patients.

This study utilizes a cross-sectional assessment using survey technique, and seeks to fill the existing knowledge gap by providing structured data on CAM usage among CLD patients seeking treatment from a tertiary care liver hospital in India. This study will provide critical insights into the use and factors associated with CAM use among CLD in India. By identifying the types, forms, and duration of CAM use, the findings can help clinicians detect potentially harmful practices early and counsel patients more effectively. The study also aims to raise awareness about the risks posed by unregulated CAM therapies, guide the development of clinical screening protocols, and inform public health strategies to regulate unauthorized practitioners. Ultimately, it seeks to promote safer healthcare practices and improve outcomes for patients with liver disease.

MATERIAL AND METHODS

A cross-sectional study design was employed to collect data.

RESULTS

Demographic and clinical variables: The participants consisted of 121(60%) males and 80(39.8%) females. As per age, most 70 (34.8%) participants were 18–40 years old. A large number 91(45.3%) belonged to the lower to upper-middle-income group. Almost half 100 (49.8%) had completed their education till graduation. For the clinical profile, Most 87(43.3%) had CLD from 1 to 3 years. The majority, 186(92.5%), were approached by the primary investigator in Out Patient Department for the data collection. A total of 170(84%) patients reported that they had no prior hospitalization for the liver disease. More than half 115(56%) had used CAM for 2–4 weeks. For 44(21.9%) neighbors were the source of information, for 42(20.9%) internet and other 39(19.4%) relatives and the remaining 34(16.9%) the friends were the source of information for the CAM.

Table 1 shows that the majority of CAM users were women, with 121 (60%) compared to 80 (39.8%) men. Herbal and dietary supplements were used by 120 (59%) women and 80 (39.8%) men. Similarly, self-help methods like yoga and meditation were reported by 121 (60%) women and 80 (39.8%) men.

Table 2 provides a detailed breakdown of CAM usage based on the I-CAM questionnaire, including the type of CAM provider, complementary treatments received from physicians, use of herbal medicines and dietary supplements, and self-help practices. Most participants visited physicians 105(52.2%), followed by homeopaths 40(20%) and herbalists 30(18.4%). Homeopathy 93(46.2%) and herbs 92(45.7%) were the most common treatments. Herbal medicines were used by 74(36.8%) participants, followed by other supplements 58(28.8%) and homeopathic medicines 43(21.4%). Among the participants Yoga 79(39.3%) and meditation 63(31.3%) were the most common self-help practices used.

Table 3 outlines the reasons for visiting CAM providers and the perceived usefulness among participants. Physicians were the most visited, with 52.2% of the participants consulting them primarily for long-term illness (66%). While 52% found physicians were very helpful, 26% reported no benefit. Homeopaths and herbalists were the next most visited providers for long-term illness, with 14% of participants finding each somewhat useful.

Table 4 provides details on the reasons for using and perceived usefulness of CAM treatments among the study participants. Homeopathy (46.3%) and herbal medicine (45.8%) were commonly used to manage chronic liver disease symptoms. Vitamins and minerals were taken by 20.4% of participants for illness management and general well-being. Perceptions of homeopathy's helpfulness were mixed, with 33% finding it very helpful, 28% somewhat helpful, and 28% not helpful at all. Herbal medicine was considered very helpful by 26% and somewhat helpful by 44%.

Table 5 details the reasons for self-help practices and their perceived effectiveness among participants. Yoga was the most common practice (39.3%), followed by meditation (31.3%), prayer (9.9%), running (6.9%), and other methods (2%). Participants mainly practiced yoga for well-being (47%) and long-term health (20%). Regarding its perceived helpfulness, 4% found yoga very helpful, 7% somewhat helpful, and 18% did not find it helpful at all.

The association between demographic variables and self-help practices was determined using Logistic regression analysis. There was no significant association found with any of the variables. Figure 1 shows an association between demographic variables and herbal medicines. The marital status and CLD duration significantly impact herbal medicine use. Married individuals were 2.5 times more likely to use herbal medicine (Odds ratio = 2.513, p = .045) compared to unmarried individuals. Herbal medicine users also had a 67.3% lower likelihood of hospitalization for CLD (OR = .327, p = .009). Additionally, longer herbal use (over one year) showed a trend towards increased usage (OR = 3.433, p = .064). These findings highlight the importance of personalized strategies for integrating herbal medicine into CLD management.

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Figure 1:

Showing the odds ratios (ORs) for the association between demographic variables and herbal medicine use among chronic liver disease (CLD) patients. *significant

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Figure 2 explains a proposed Causal pathway of factors associated with CAM use and its association with the risk of hospitalization. It is observed that for Predicting herbal medicine use, marital status (married vs unmarried) and duration of CLD could be important input features. Predicting hospitalization risk - whether a patient uses herbal medicine could be a strong negative predictor of hospitalization likelihood.

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Figure 2:

A proposed causal pathway of factors associated with complemenatry and alternative medicine (CAM) use.

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Table 6 shows the names of various CAM medicines used by the study participants. The commonly used drugs and supplements were Aloe vera juice, Liver 52, and Capsule Livam Care. There are many other types of CAM reported to be used by the patients, as explained above. The names given in the above table are purely based on recall of the patient, and in some cases, the patient showed an image of the used medicine.

DISCUSSION

The present study found that the majority of CAM users (51.7%) were between the ages of 41-60, with 13.7% over the age of 60. These results align with Gelow et al. (2022), which reported a mean CAM user age of 50.1 years (Standard deviation ±6.1 years).^[8] The study highlights the prevalence of various CAM treatments among CLD patients. Similarly a study on the Korean population done by Kim S. found that a significant number of liver disease patients used CAM therapies, particularly herbal medicine and acupuncture, due to dissatisfaction with conventional treatments and cultural beliefs.^[4]

In contrast, a U.S. study on liver disease patients reported a low prevalence of CAM use, attributed to higher trust in conventional medicine and stricter regulatory environments. The current study indicates that most patients turned to CAM due to chronic illness and dissatisfaction with conventional treatments, a trend also seen in diabetic patients, where cultural practices and dissatisfaction with conventional treatments were major factors in CAM use.^[5]

A significant portion of participants in this study (45.3%) belonged to the upper socioeconomic class, while 39.8% were from the upper middle class, suggesting that higher socioeconomic status is associated with greater CAM use. Among CAM users, 74 (36%) used herbal medicines, followed by 58 (28.8%) who used other supplements, 43 (21.4%) who used homeopathic treatments, and 26 (13%) who used vitamin supplements. These findings are somewhat similar to another study, where vitamins and dietary supplements were reported to be the most commonly used therapies, followed by herbal medicine and homeopathy, though differences are likely due to variations in methodology, population, and cultural factors.^[6]

In this study, the most common physical CAM practices were meditation (31.3%) and yoga (39.3%), comparable to another study, where exercise (49.5%) and yoga (34%) were reported to be the most frequently practiced CAM strategies.^[10]

In the present study, using CAM for more than a year was significantly associated with self-help practices (p = 0.03, OR = 4.814). Marital status (p = 0.04, OR = 2.513) and hospitalization for CLD (p = 0.00, OR = 0.327) were also significantly linked to herbal medicine use. These findings differ from a study done by Ferucci et al., (2010), where associations with higher education, income, and certain CLD causes (e.g., alcohol, hepatitis C & B) were determined, although prior hospitalization for CLD was similarly significant in both studies.^[10]

CONCLUSION

The study emphasizes the significant use of CAM among patients with chronic liver disease, influenced by factors such as managing chronic illness, perceived effectiveness, and recommendations from trusted sources. Understanding these factors is essential for healthcare providers to effectively integrate CAM with conventional treatments, promoting a holistic approach to patient care.