Complementary and alternative medicine (CAM) is prevalent in East Asia. However, information on CAM in East Asian patients with inflammatory bowel disease (IBD) is scarce. We aimed to profile the prevalence and pattern of CAM use among East Asian IBD patients and to identify factors associated with CAM use. We also compared physicians’ perspectives on CAM.
Patients with IBD from China, Japan, and South Korea were invited to complete questionnaires on CAM use. Patient demographic and clinical data were collected. Logistic regression analysis was applied for predictors of CAM use. Physicians from each country were asked about their opinion on CAM services or products.
Overall, 905 patients with IBD participated in this study (China 232, Japan 255, and South Korea 418). Approximately 8.6% of patients with IBD used CAM services for their disease, while 29.7% of patients sought at least 1 kind of CAM product. Current active disease and Chinese or South Korean nationality over Japanese were independent predictors of CAM use. Chinese doctors were more likely to consider CAM helpful for patients with IBD than were Japanese and South Korean doctors.
In 8.6% and 29.7% of East Asian patients with IBD used CAM services and products, respectively, which does not differ from the prevalence in their Western counterparts. There is a significant gap regarding CAM usage among different Asian countries, not only from the patients’ perspective but also from the physicians’ point of view.
Inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), is a disabling and chronic relapsing inflammatory condition of the bowel. Without optimal treatment, it may cause irreversible bowel damage and lead to a negative impact on patients’ quality of life. Although IBD is the most prevalent disease in Western countries, the incidence of the disease has been rapidly increasing in East Asia, making it a global disease [
The cause of IBD is unknown, and there is no absolute cure. Although several therapeutic advances have been made in recent years, the unsatisfactory response rate, increased risk of relapse over time and adverse effects of therapy remain unmet clinical needs for the conventional management of IBD [
CAM is defined as a group of diverse medical and health care systems, practices, and products that are not presently considered part of conventional medicine [
With the substantial popularity and acceptance of CAM in the general population, the prevalence of CAM use differs by country because of various economic, social and cultural factors. CAM use is considered to be widespread in East Asia because traditional oriental medicine, which is one of the main streams of CAM, originated in this area [
This was a cross-sectional, multinational study conducted in China, Japan, and South Korea from November 2017 to March 2018. Patients diagnosed with IBD for at least 6 months in tertiary hospitals were eligible for the study. IBD diagnosis was made based on a detailed history, physical examination, and combination of endoscopic features, histology, radiographic findings, and laboratory investigations. Participants who were younger than 18 years old or who were not able to read questionnaires were excluded. On an outpatient basis, they were consecutively invited to complete a questionnaire on CAM use over the past 12 months. Patient demographic and clinical data were collected. Regarding physicians’ perspectives on CAM, we invited doctors to participate in the study using the network in the Clinical Research Committee of the Asian Organization for Crohn’s and Colitis. We asked them to report on whether CAM is beneficial or recommendable for their IBD patients. Questionnaires used in the study are provided as
Patient demographic data, such as age, comorbidities, and sex, were collected. comorbidities included hypertension, diabetes mellitus, renal disease, respiratory disease, atopy, and malignancy. Clinical data included disease duration, disease activity, current medication, previous IBD-related hospitalization, and surgery history. The disease activity of CD and UC was assessed by the Harvey-Bradshaw index (HBI) and the Simple Clinical Colitis Activity Index (SCCAI), respectively. Scores equal to or more than 5 reflected active disease on both the HBI and SCCAI [
CAM was categorized into services and products; services in the study included massage, acupuncture, naturopathic medicine, homoeopathy, relaxation, reflexology, aromatherapy, hypnosis, moxibustion or cupping, spiritual or religious healing, and chiropractic therapy, whereas products in the study included herbal remedies, ginseng, deer antler, Chinese medicine, St. John’s wort, chamomile, lavender, ginkgo biloba, kava kava, vitamins, probiotics, fish oils, and glucosamine [
The sample size was calculated on the assumption that there will be a 15% difference in the prevalence of CAM use between countries (60% vs. 45%). With a 20% withdrawal rate and 80% power to detect such a difference at a two-tailed significance level of 0.05, at least 220 patients from each country were required.
Differences in categorical data among groups were examined by using chi-square or Fisher exact test. For continuous variables among 3 countries, analysis of variance was used. The pairwise Wilcoxon rank-sum test was used for multiple measurements of the nonparametric data among groups. The prevalence of CAM was compared among countries with adjustment of confounders such as age, duration of disease, sex, comorbidities, disease activity, current medications and previous history of surgery and admission. Independent factors associated with CAM use were analyzed by logistic regression. Variables with
Fifteen institutions from 3 countries participated (China 5, Japan 3, and Korea 7), and 905 IBD patients were enrolled in the study (China 232, Japan 255, and South Korea 418). There was a significant difference in baseline characteristics among 3 countries (
Korean patients with IBD were generally more likely to use CAM services (
For CAM products, 29.7% of East Asian patients with IBD used at least 1 type of CAM product for the management of IBD during the last year with Chinese patients being the most common user (China 50.4% vs. Japan 12.5% vs. Korea 28.7%,
In univariate analysis, Chinese or Korean nationality (
Physicians were recruited for surveys from China (n = 20), Japan (n = 104), and South Korea (n = 29). The characteristics of these physicians are described in
Then, we tried to determine whether there was a difference regarding overall perceptions toward CAM among physician groups by measuring the median number of beneficial/recommendable forms of CAM considered by physicians from each country. Chinese doctors had a significantly higher median number (interquartile range) of beneficial/recommendable CAM services (China 2 [1–4] vs. Japan 1 [0–3] vs. Korea 1 [0–2]) or products (China 3 [3–5] vs. Japan 2 [1–3] vs. Korea 3 [2–3]) than did doctors from the other 2 countries, while there was no difference between Japanese and South Korean doctors (
This cross-sectional, multinational study demonstrated that approximately 1 in 10 and 1 in 3 East Asian patients with IBD used CAM services and products, respectively, for the management of IBD during the past year. Moxibustion/cupping was the most used CAM service by patients (2.9%) (
CAM use is highly prevalent among patients with IBD. In the studies reporting current or past CAM use together, the prevalence spanned a wide range (21%–77%) among patients with IBD [
We found a significant difference regarding perceptions of CAM use among patients in different countries; Chinese and South Korean patients are more likely to utilize CAM for IBD than are Japanese patients (
Intriguingly, there was a gap in the perception of CAM between South Korean patients with IBD and doctors; South Korean patients favored CAM (
Apart from the nationality of patients, we identified current active disease as another independent predictor of CAM use, which is consistent with the results of previous study [
Of note, relaxation was considered a helpful form of CAM for IBD by most physicians, which is in line with the position statement of the European Crohn’s and Colitis Organization [
We acknowledged the failure to obtain information on education level, socio-economic status such as income, insurance system and adherence to IBD treatment of patients from each country as the main limitation of the study because these variables are known to influence CAM usage [
In summary, this study demonstrated that the prevalence of CAM use for IBD in East Asian countries does not differ from the prevalence in their Western counterparts (8.6% for CAM services and 29.7% for CAM products). We found that there was a significant gap with respect to CAM usage among different East Asian countries, not only from the patients’ perspective but also from the physicians’ point of view. This disparity might be attributed to the different historical and cultural backgrounds of traditional medicine in each country.
The authors received no financial support for the research, authorship, and/or publication of this article.
Park DI is an editorial board member of the journal but was not involve in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflicts of interest relevant to this article were reported.
Study concept, design, analysis of data: Kim ES. Study concept, design: Ogata H. Substantial contribution to the acquisition and interpretation of data for the work: Tae CH, Jung SA, Park DI, Im JP, Eun CS, Yoon H, Jang BI, Fukuhara K, Hirai F, Ohtsuka K, Liu J, Cao Q. Drafting of the manuscript: Kim ES. Critical revision of the manuscript: Ogata H. Approval of final manuscript: all authors.
Supplementary materials are available at the Intestinal Research website (
Supplementary Table 1. Prevalence of CAM Use According to Different Indications Among Patients with IBD from 3 Countries
Supplementary Table 2. Characteristics of Physicians from 3 Countries
Supplementary Material. Questionnaire
The prevalence of complementary and alternative medicine service (A) and product (B) usage among patients with inflammatory bowel disease from 3 countries. The
Comparison of physicians’ perspectives on complementary and alternative medicine (CAM) services (A) and products (B) for inflammatory bowel disease among 3 countries. The width of the box indicates the sample size of participants from each country. The
Baseline Characteristics of Patients in the Study
Characteristics | China (n = 232) | Japan (n = 255) | Korea (n = 418) | |
---|---|---|---|---|
Age at enrollment (yr) | 38.8 ± 14.2 | 43.2 ± 13.7 | 40.8 ± 15.3 | 0.001 |
Disease duration (yr) | 4.1 ± 4.4 | 10.8 ± 8.2 | 7.0 ± 6.2 | < 0.001 |
Male sex | 143 (61.6) | 129 (50.6) | 269 (64.5) | 0.001 |
Comorbidities | 40 (17.2) | 115 (45.1) | 124 (29.7) | < 0.001 |
SCCAI | 5.1 ± 4.2 | 0.7 ± 1.5 | 1.9 ± 2.1 | < 0.001 |
HBI score | 3.8 ± 2.5 | 2.3 ± 2.6 | 2.3 ± 2.3 | < 0.001 |
Active disease at enrollment | 109 (47.0) | 46 (18.0) | 53 (12.7) | < 0.001 |
Current medications | ||||
Steroid | 54 (23.3) | 26 (10.2) | 40 (9.6) | < 0.001 |
Thiopurine | 45 (19.4) | 106 (41.6) | 135 (32.4) | < 0.001 |
Tacrolimus | 0 | 8 (3.1) | 0 | < 0.001 |
Anti-TNFs | 51 (22.1) | 59 (23.1) | 129 (30.9) | 0.018 |
Previous surgery related with IBD | 52 (22.4) | 23 (9.0) | 76 (18.2) | < 0.001 |
Previous admission related with IBD | 222 (95.7) | 90 (35.3) | 208 (49.9) | < 0.001 |
Values are presented as mean±standard deviation or number (%). Active disease was defined as HBI ≥5 for Crohn’s disease and SCCAI ≥5 for ulcerative colitis.
SCCAI, Simple Clinical Colitis Activity Index; HBI, Harvey-Bradshaw index; TNF, tumor necrosis factor; IBD, inflammatory bowel disease.
Prevalence of Complementary and Alternative Medical Services Usage in Inflammatory Bowel Disease Patients According to Countries
Variable | China (n = 232) | Japan (n = 255) | Korea (n = 418) | Total (n = 905) | |
---|---|---|---|---|---|
Massage | 5 (2.2) | 2 (0.8) | 4 (1.0) | 11 (1.2) | 0.166 |
Acupuncture | 5 (2.2) | 2 (0.8) | 16 (3.8) | 23 (2.5) | 0.995 |
Naturopathic medicine | 4 (1.7) | 1 (0.4) | 1 (0.2) | 6 (0.6) | 0.195 |
Homoeopathy | 2 (0.9) | 0 | 7 (1.7) | 9 (0.9) | 0.898 |
Relaxation | 6 (2.6) | 2 (0.8) | 2 (0.5) | 10 (1.1) | 0.626 |
Reflexology | 0 | 4 (1.6) | 5 (1.2) | 9 (0.9) | 0.871 |
Aromatherapy | 0 | 0 | 0 | 0 | NA |
Hypnosis | 0 | 0 | 0 | 0 | NA |
Moxibustion or cupping | 8 (3.4) | 0 | 19 (4.5) | 27 (2.9) | 0.051 |
Spiritual or religious healer | 3 (1.3) | 0 | 1 (0.2) | 4 (0.4) | 0.108 |
Chiropractic | 7 (3.0) | 1 (0.4) | 2 (0.5) | 10 (1.1) | 0.047 |
CAM ≥ 2 services | 8 (3.4) | 0 | 14 (3.3) | 22 (2.4) | 0.027 |
Any CAM service | 20 (8.6) | 13 (5.1) | 45 (10.8) | 78 (8.6) | 0.179 |
Values are presented as number (%).
The comparison was adjusted with age, duration of disease, sex, comorbidities, disease activity, current medications and previous history of surgery and admission.
CAM, complementary and alternative medicine; NA, not applicable.
Prevalence of Complementary and Alternative Medical Products Usage in Inflammatory Bowel Disease Patients According to Countries
Variable | China (n = 232) | Japan (n = 255) | Korea (n = 418) | Total (n = 905) | |
---|---|---|---|---|---|
Herbal remedies | 22 (9.5) | 4 (1.6) | 13 (3.1) | 39 (4.3) | 0.002 |
Ginseng | 1 (0.4) | 0 | 14 (3.3) | 15 (1.6) | 0.814 |
Deer antlers | 0 | 0 | 2 (0.5) | 2 (0.2) | 0.368 |
Chinese medicine (drugs) | 29 (12.5) | 5 (2) | 33 (7.9) | 67 (7.4) | < 0.001 |
St. John’s wort | 0 | 0 | 0 | 0 | NA |
Chamomile | 1 (0.4) | 1 (0.4) | 4 (1.0) | 6 (0.6) | 0.502 |
Lavender | 0 | 0 | 1 (0.2) | 1 (0.1) | 0.486 |
Ginkgo biloba | 0 | 0 | 0 | 0 | NA |
Kava kava | 0 | 0 | 0 | 0 | NA |
Vitamins | 70 (30.2) | 2 (0.8) | 36 (8.6) | 108 (11.9) | < 0.001 |
Probiotics | 81 (34.9) | 19 (7.5) | 75 (17.9) | 175 (19.3) | < 0.001 |
Fish oils | 1 (0.4) | 3 (1.2) | 5 (1.2) | 9 (0.9) | 0.505 |
Glucosamine | 19 (8.2) | 0 | 5 (1.2) | 24 (2.6) | < 0.001 |
CAM ≥ 2 products | 70 (30.2) | 8 (3.1) | 52 (12.4) | 130 (14.3) | < 0.001 |
Any product | 117 (50.4) | 32 (12.5) | 120 (28.7) | 269 (29.7) | < 0.001 |
Values are presented as number (%).
The comparison was adjusted with age, duration of disease, sex, comorbidities, disease activity, current medications and previous history of surgery and admission.
CAM, complementary and alternative medicine; NA, not applicable.
Associated Factors with Complementary and Alternative Medicine in Patients with IBD
Factor | CAM service |
CAM product |
||||||||
---|---|---|---|---|---|---|---|---|---|---|
Univariate analysis |
Multivariate analysis |
Univariate analysis |
Multivariate analysis |
|||||||
User (n=78) | Nonuser (n=827) | OR (95% CI) | User (n=269) | Nonuser (n=636) | OR (95% CI) | |||||
Age at enrollment (yr) | 39.54 ± 13.43 | 41.09 ± 14.74 | 0.370 | 39.39 ± 13.97 | 41.62 ± 14.87 | 0.035 | 0.99 (0.98–1.00) | 0.321 | ||
Disease duration (yr) | 7.34 ± 5.86 | 7.29 ± 6.94 | 0.955 | 6.65 ± 6.33 | 7.57 ± 7.10 | 0.068 | ||||
Male sex | 46 (59.0) | 495 (59.9) | 0.904 | 158 (58.7) | 383 (60.3) | 0.657 | ||||
Comorbidities | 25 (32.1) | 254 (30.7) | 0.799 | 67 (24.9) | 212 (33.3) | 0.012 | 0.91 (0.64–1.29) | 0.578 | ||
Disease | 0.808 | 0.940 | ||||||||
CD | 31 (39.7) | 314 (38) | 103 (38.3) | 242 (38.1) | ||||||
UC | 47 (60.3) | 513 (62) | 166 (61.7) | 394 (61.9) | ||||||
Countries | 0.040 | < 0.001 | ||||||||
China | 20 (25.6) | 212 (25.6) | 1.35 (0.64–2.86) | 0.428 | 117 (43.5) | 115 (18.1) | 5.15 (3.10–8.58) | < 0.001 | ||
Japan | 13 (16.7) | 242 (29.3) | 1 (reference) | 32 (11.9) | 223 (35.1) | 1 (reference) | ||||
Korea | 45 (57.7) | 373 (45.1) | 2.31 (1.21–4.41) | 0.011 | 120 (44.6) | 298 (46.9) | 2.73 (1.77–4.22) | < 0.001 | ||
Active disease | 29 (37.2) | 180 (21.8) | 0.003 | 2.46 (1.45–4.19) | 0.001 | 87 (32.3) | 122 (19.2) | < 0.001 | 1.45 (1.01–2.08) | 0.043 |
Steroid | 10 (12.8) | 110 (13.3) | 0.946 | 47 (17.5) | 73 (11.5) | 0.018 | 1.27 (0.83–1.96) | 0.273 | ||
Thiopurine | 24 (30.8) | 262 (31.7) | 0.899 | 81 (30.1) | 205 (32.3) | 0.533 | ||||
Anti-TNFs | 29 (37.2) | 210 (25.5) | 0.031 | 1.59 (0.96–2.60) | 0.068 | 68 (25.4) | 171 (26.9) | 0.680 | ||
Previous surgery related with IBD | 14 (18.2) | 137 (16.6) | 0.749 | 51 (19.0) | 100 (15.7) | 0.243 | ||||
Previous admission related with IBD | 47 (61.0) | 473 (57.2) | 0.548 | 192 (71.4) | 328 (51.7) | < 0.001 | 1.28 (0.89–1.85) | 0.121 |
Values are presented as mean±standard deviation or number (%). Active disease was defined as Harvey-Bradshaw index ≥5 for CD and Simple Clinical Colitis Activity Index ≥5 for UC.
IBD, inflammatory bowel disease; CAM, complementary and alternative medicine; OR, odds ratio; CI, confidence interval; CD, Crohn’s disease; UC, ulcerative colitis; TNF, tumor necrosis factor.