DOI:10.1093/jncimonographs/lgu031
© The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: [email protected].
Associations Between Healthy Lifestyle Behaviors and Complementary and Alternative Medicine Use: Integrated Wellness Joelle B. Karlik, Elena J. Ladas, Deborah H. Ndao, Bin Cheng, YuanYuan Bao, Kara M. Kelly Correspondence to: Kara M. Kelly, MD, Columbia University Medical Center, 161 Fort Washington Avenue, 7th floor, New York, NY 10032 (e-mail: kk291@ columbia.edu).
Background
Conventional medicine, lifestyle modification, and complementary and alternative medicine (CAM) are potential strategies to decrease the risk of late effects in pediatric cancer survivors. This study aimed to compare the characteristics and usage patterns of CAM and lifestyle therapies among survivors of childhood cancer.
Methods
We report the results of a cross sectional survey comparing usage patterns of CAM and lifestyle therapies among childhood cancer survivors. CAM therapies were defined by NCCAM classifications and lifestyle therapies were defined as dietary changes, conventional supplements with dietary reference intake values, and exercise.
Results
One hundred fifty-five (95%) patients approached in person and 45 (34%) patients approached by mail consented to participate. Sixty-eight used at least one lifestyle therapy and 58% used at least one CAM therapy. CAM users had 4.7 times the odds of using lifestyle therapies than non-CAM users (P < .0001); the odds of using dietary change and conventional supplements was greater in CAM users than non-CAM users (odds ratio [OR] = 3.55, P < .0001 and OR = 4.80, P < .0001 respectively). Use of the top three CAM therapies was associated with overall lifestyle therapy use (OR = 12.52 and P < .0001, OR = 7.071 and P = .0004, and OR = 2.925 and P = .0089 for juicing, yoga/movement, and touch therapies, respectively). Lifestyle therapies and CAM had similar perceived efficacy (92%–90%, respectively).
Conclusions
This data reports a strong association between CAM and lifestyle therapies and may identify a population with commitment to general wellness. Use of one therapy may promote use of other therapies and this potential synergistic relationship can be targeted in future interventions.
J Natl Cancer Inst Monogr 2014;50:323–329
Survivors of childhood cancer often experience physical and psychological long-term complications (late effects) due to the necessary treatment for cancer. Multiple surveys have found that the majority of survivors of childhood cancer practice unhealthy or risky lifestyle behaviors (1–5) that may contribute to certain late effects including metabolic syndrome, osteoporosis, and dyslipidemia. Conventional medicine, healthy lifestyle behaviors, and complementary and alternative medicine (CAM) provide various modalities to decrease the risk of these late effects or to treat existing late effects in these populations. New strategies that promote healthy lifestyle practices may decrease unhealthy behaviors and the risk of developing late effects that may be accelerated by unhealthy behaviors among cancer survivors. The National Center for Complementary and Alternative Medicine (NCCAM) has highlighted the potential role of CAM in promoting healthy lifestyle behaviors in its most recent strategic objectives for 2011–2015 (6). Different strategies may be used in concert with conventional treatments to address a similar concern; for example, meditation and exercise may be used simultaneously to address anxiety in a pediatric cancer survivor. In addition,
a commitment to overall wellness in some CAM users has been described (7–9) and may also extend to lifestyle behaviors as well. However, NCCAM describes a lack of research on this subject and an aim to translate previously measured associations between CAM and healthy lifestyle behaviors into successful lifestyle interventions. Initial research has suggested that adult and geriatric CAM users may have an increased use of healthy lifestyle behaviors and a strong focus on overall wellness. Analyses of data from the National Health Interview Study (NHIS) data, 2002 and 2007, found that adult CAM users were more likely to use exercise and less likely to be obese than adults who did not use CAM (7,10). Associations of CAM with exercise (7,10–13), higher vegetable intake (12,14), lower fat or lipid intake (12,14), and smoking cessation or decreased smoking (10,11,13) have been reported in adults or geriatric populations. Pediatric CAM modalities in the cancer survivor population are often used to decrease stress and promote general health and healing (15), goals that can also be targeted with healthy lifestyle behaviors. However, pediatric research in concurrent CAM and healthy lifestyle behaviors is limited and associations between the two modalities have not been investigated (15–16).
Journal of the National Cancer Institute Monographs, No. 50, 2014 323
In this study, we sought to compare the characteristics and usage patterns of CAM and lifestyle therapies among survivors of childhood cancer. We hypothesized that CAM use supports the adoption of healthy lifestyle behaviors in survivors of childhood and adolescent cancer.
Methods Study Respondents Study respondents were childhood cancer survivors between the age of 2 and 33 at time of survey and had completed the prescribed cancer treatment for at least 3 months. Respondents were contacted during a routine scheduled appointment as part of the standard of care at the Herbert Irving Child and Adolescent Oncology Center, Columbia University Medical Center (CUMC) or by mail. Informed consent was obtained from all patients, parents, or legal guardians. For respondents under the age of 18, the parent or legal guardian was approached for participation. Assent was obtained from children 7 years of age and older. The CUMC Institutional Review Board approved this study. Administration of the survey occurred between June 2005 and July 2008. Survey Instrument and Methods Interviews were conducted using a modified version of a survey previously described in Kelly et al. (16); adaptations were made for survivors of child and adolescent cancer. Interviewers were not involved in the medical care of the patient and administered the survey in-person, over the phone, or through the mail. The survey included demographic information, CAM and lifestyle therapies used, purpose and referral for use, and communication with physician about use. Clinical information was collected from medical charts. Data from completed surveys were entered into a database, open-ended questions were thematically coded and categorized based on responses, and the data was checked for accuracy. Specific CAM therapies were categorized based on NCCAM’s classifications: biologically based therapies (e.g., herbal or botanical remedies; vitamins, minerals, and other natural products; juicing for medicinal purposes; ointments or creams derived from herbal or nutrition supplements), manipulative and body-based therapies (e.g., chiropractor; massage/body work; movement therapies), mind-body therapies (e.g., aromatherapy; imagery; yoga; acupuncture), energy-based therapies (e.g., reiki; qi-gong) and whole medical systems (e.g., homeopathy; Chinese medicine). Lifestyle therapies were distinguished as the adoption of more conventionally accepted healthy behaviors including dietary changes (e.g., increasing fruits and vegetables; eliminating fried foods), conventional supplements (e.g., multivitamin; calcium), and exercise practices (e.g., jogging; karate). Conventional supplements were defined as any supplement with a dietary reference intake (DRI) and included multivitamins, vitamin A, calcium and vitamin D, vitamin E, potassium, vitamin C, B vitamins, selenium, and zinc. Reasons for use were classified based off previous NHIS categories of general wellness (general health and healing, fitness and overall strengthening, immune support, mental and emotional health, relaxation/stress management, fatigue/energy, and improve nutrition) and symptom management [cancer prevention, detoxification, 324
pain, skin/hair, nausea, weight loss, weight gain, rehabilitation, insomnia/sleep, loss of appetite, gastrointestinal relief, concentration/attention, other (7)]. Sources of referral were categorized into three categories: biomedical provider (doctor, nurse, speech therapist, PT, pharmacist, dentist, nutritionist, etc.), integrative provider (herbalist, massage therapist, acupuncturist, Reiki master, etc.), and other sources of information (self, parents, other family members, friends, neighbors, media outlets, other). Statistical Analysis SAS computer program (SAS 9.2) was used for analysis. Demographic information was summarized as mean and standard deviation for continuous variables and count and percentage for categorical variables for all the subjects. The demographic information was compared between CAM users/non-CAM and lifestyle/non-lifestyle users using either a two-sample t-test for a continuous variable and a Chi-square test or a Fisher’s exact test for a categorical variable. Associations between CAM and healthy lifestyle behavior use were examined using a Chi-square or Fisher’s exact test. Since treatments may have been used for multiple indications or multiple treatments may have been used for the same indication, survey items concerning treatment use were analyzed by overall therapy category and individual therapy type.
Results Demographics One hundred fifty-five (95%) patients approached in person and 45 (34%) patients approached by mail consented to participate in the study, which resulted in 100 males (51%) who had completed the interview. Of the three patients that did not complete the survey, one patient relapsed and two patients were lost to follow-up. Sixty percent of surveys were completed by the parent (n = 118), 39% were completed by patients (n = 76), and 2% were completed by grandparents or guardians (n = 3). No association was found between respondent and use of lifestyle therapies or CAM therapies. The average age of survey respondent was 14.5 years (standard deviation [SD] = 6.2 years). Fifty-three percent of patients identified themselves as a non-white ethnicity (n = 105). The demographic characteristics of users and non-users of CAM and lifestyle therapies are presented in Table 1. Overall Use of CAM and Lifestyle Therapies Fifty-eight percent (n = 115) of survey participants used at least one CAM therapy and 68% (n = 134) used at least one healthy lifestyle behavior. The most popular CAM therapies included biologically based therapies (42%), mind-body therapies (30%), manipulative and body-based therapies (27%), energy healing therapies (8%), and whole medical systems (3%). Forty-eight percent (n = 95) of survey respondents used dietary modification, 45% (n = 88) used conventional supplements, and 21% (n = 42) used exercise. Predictors of CAM and Lifestyle Behaviors Male gender and increased parental education were significantly associated with use of lifestyle behaviors (odds ratio [OR] = 2.13, P = .0148 [95% confidence interval (CI) = 1.15–3.93]; risk difference [RD] = 1.09, P = .0395 [95% CI = 1.004–1.19], respectively). Journal of the National Cancer Institute Monographs, No. 50, 2014
No other demographic variables were associated with overall use of lifestyle or CAM behaviors. Ninety-four participants used both CAM and lifestyle therapies, accounting for 48% of the overall survey population, 82% of CAM users, and 70% of lifestyle users. The odds of using a lifestyle therapy among CAM-users was 4.7-fold higher compared to non-CAM users (P < .0001, 95% CI = 2.48–8.93). The majority of users of CAM (65%) also adopted healthy dietary changes, 59% (n = 68) used conventional supplements, and 25% (n = 29) adopted an exercise regimen. The odds of overall dietary change or conventional supplement use were also greater in CAM users compared to non-CAM users (OR = 3.55 [P < .0001, 95% CI = 1.94–6.47];
OR = 4.80 [P < .0001, 95% CI = 2.40–8.39], respectively). CAM use was also associated with the two most popular dietary changes, increasing fruit or vegetable intake and decreasing fried, junk, or fast food, compared to non-CAM users (OR = 2.28 [P = .011, 95% CI = 1.21–4.70]; OR = 4.28 [P = .0026, 95% CI = 1.56–11.71], respectively). However, there was no significant difference found between the odds of exercise between CAM and non-CAM users as the prevalence of exercise among CAM users and the overall study population was nearly equivalent (25% and 21%, respectively). Table 2 compares reasons for use, sources of referral, perceived efficacy, and disclosure rate for overall CAM therapies and healthy lifestyle behaviors. For both CAM therapies and healthy
Table 1. Demographic characteristics* Characteristic Gender Female Male Patient race/ethnicity Black Hispanic White Asian Other Diagnosis Leukemia/lymphoma Brain tumor Solid tumor Other Parent school years completed Time from treatment completion to survey, y
All, No. (%) (N = 197)
No CAM use, No. (%) (N = 82)
CAM use, No. (%) (N = 115)
P
No lifestyle use, No. (%) (N = 63)
Lifestyle use, No. (%)
.86 97 (49) 100 (51)
41 (50) 41 (50)
56 (49) 59 (51)
21 (11) 66 (33) 92 (47) 5 (2) 13 (7)
12 (15) 26 (32) 39 (47) 1 (1) 4 (5)
9 (8) 40 (35) 53 (46) 4 (3) 9 (8)
110 (56) 23 (12) 59 (30) 5 (2) 14.5 ± 3.6
50 (61) 7 (8) 22 (27) 3 (4) 14.1 ± 3.6
60 (52) 16 (14) 37 (32) 2 (2) 14.7 ± 3.5
4.5 ± 4.0
4.6 ± 4.1
4.4 ± 3.9
P .0148†
39 (62) 24 (38)
58 (43) 76 (57)
9 (14) 21 (33) 30 (48) 1 (2) 2 (3)
12 (9) 45 (34) 62 (46) 4 (3) 11 (8)
.24
31 (49) 7 (11) 21 (33) 4 (6) 13.7 ± 4.0
79 (59) 16 (12) 38 (28) 1 (1) 14.8 ± 3.3
.0385†
.94
3.9 ± 4.9
3.5 ± 4.3
.3658
.43
.8594
.39
.1113
* The denominators for statistics shown exclude persons with unknown lifestyle information. CAM = complementary and alternative medicine. † P < .05.
Table 2. Characterization of overall complementary and alternative medicine (CAM) and lifestyle use Reasons for use* General wellness Symptom management Referral source† Conventional provider Integrative provider Other sources Perceived effectiveness Not effective Somewhat Very effective Do not know Disclosed use* Yes No Do not know
Overall CAM therapies, No. (%)
Overall lifestyle therapies, No. (%)
284 (59) 194 (41)
193 (73) 73 (27)
44 (11) 86 (22) 266 (67)
75 (28) 28 (11) 162(61)
13 (4) 112 (30) 228 (62) 15 (4)
8 (3) 77 (29) 160 (60) 20 (8)
191(51) 179 (48) 1 (1)
220 (66) 75 (34) —
* P < .05. † Conventional provider: physician, nurse, speech therapist, physical therapist, pharmacist, dentist, nutritionist, etc. Integrative provider: massage therapist, acupuncturist, Reiki master, etc. Other sources: self, parents, other family members, friends, neighbors, media outlets, etc.
Journal of the National Cancer Institute Monographs, No. 50, 2014 325
lifestyle behaviors, the majority of therapies were initiated after completion of cancer treatment. Both lifestyle and CAM therapies had comparable perceived positive efficacy (90% and 92%, respectively). A larger proportion of CAM therapies were referred by an integrative provider and a larger proportion of healthy lifestyle behaviors were referred by a biomedical provider. Healthy lifestyle behaviors had higher odds of being used for general wellness compared to CAM therapies (OR = 1.81 [P = .0003, 95% CI = 1.30–2.51]), but the majority of CAM therapies were relied upon for general wellness as well. Healthy lifestyle behaviors had significantly greater odds of being disclosed to physicians compared to CAM therapies (OR = 1.71 [P = 0.0012, 95% CI = 1.23–2.38]). Associations Between Lifestyle and CAM Therapies Table 3 presents the significant associations between lifestyle and CAM therapies. The most common CAM therapies were juicing, yoga/movement therapies, and touch therapies, and use of these were also associated with overall healthy lifestyle behaviors (OR = 12.52 [P < .0001, 95% CI = 2.92–53.70]; OR = 7.07 [P = .0004, 95% CI = 2.08–24.00]; OR = 2.93 [P = .0089, 95% CI = 1.28–6.70], respectively). The three most frequently used CAM therapies were significantly associated with the majority of lifestyle therapies. A high odds ratio was observed between herbal supplement use and use of conventional supplements (OR = 2.43, P = .0342, 95% CI = 1.05–5.62). However, no significant associations were observed between exercise and touch therapies and conventional supplements and juicing. Table 4 compares reasons for use, sources, of referral, perceived efficacy, and disclosure rate for specific CAM therapies and healthy lifestyle behaviors. The characterization of specific therapies was largely similar to the previous characterization of overall CAM use and healthy lifestyle behaviors in that there was high perceived efficacy and primarily used for general wellness.
Discussion This is the first study to explore the association of the use of CAM with healthy lifestyle behaviors among an ethnically diverse population at high risk for lifestyle-related chronic diseases. We observed a high prevalence of the combination of CAM and healthy lifestyle behaviors and repeated associations between the two types of therapies in pediatric cancer survivors. This pattern remained when looking at individual therapies as well. Similarities between
lifestyle behaviors and CAM therapies included highly perceived efficacy and use for general wellness. While the reported associations between CAM and healthy lifestyle therapies appear strong and occur on overall and specific therapy levels, the results do not elucidate the nature of such a relationship. These findings suggest that this pediatric survivor population holds a strong overall commitment to wellness. However, investigation into a causal pathway between CAM therapies and healthy lifestyle behaviors is warranted (6). The use of one therapy may promote use of other therapies but the directionality of these associations is unknown. Previous research has described two separate CAM populations, health promotion or symptom relief (7,8,17,18), which our study supports. Cancer-specific CAM usage reasons, including reduction of relapse and subsequent cancer prevention, were included in these two separate populations for our analysis (see “Methods”). However, lifestyle therapy use between these CAM populations may vary, including cancer survivors. For example, “health promotion” CAM users may be more likely to use lifestyle behaviors than “symptom relief” CAM users. Further research into healthy lifestyle behavior use in these different groups of CAM users may better define the populations and clarify the associations between each group and healthy lifestyle behaviors. Compared to healthy controls, cancer survivors may require alternative interventions due to their targeted CAM uses. Better characterization may also increase the likelihood of successful interventions to increase lifestyle behavior use. Multiple studies have found that pediatric cancer survivors continue to practice unhealthy lifestyle behaviors, especially in the adolescent population (2–5). In our study, the majority of both CAM and lifestyle therapies were initiated after treatment completion, possibly identifying a “teachable moment.” “Teachable moments” have been described at the time of cancer diagnosis previously (19); our data suggests that a second “teachable moment” may occur during cancer survivorship as well. Some studies in adolescent and adult cancer survivor populations challenge this pattern (2,20). Further research into the period after cancer treatment completion may clarify the optimal timing for a healthy lifestyle behavior intervention. For some survivors, education on CAM therapies from reliable practitioners may be a strategy to promote general wellness and lead into healthy lifestyle behaviors. The majority of referrals for both CAM and healthy lifestyle behaviors were not obtained by a professional provider. Previous studies have shown that adult cancer survivors cite referrals from
Table 3. Associations between specific complementary and alternative medicine (CAM) therapies and healthy lifestyle behaviors* CAM therapy
Healthy lifestyle behavior
OR
P
95% CI
Juicing Yoga/movement therapies Touch therapies Yoga/movement therapies Juicing Touch therapies Yoga/movement therapies Touch therapies Juicing
Dietary change Dietary change Conventional supplement Conventional supplement Exercise Dietary change Exercise Exercise Conventional supplements
9.33 3.84 2.94 2.93 2.76 2.42 2.33 2.05 1.79
© The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: [email protected].
Associations Between Healthy Lifestyle Behaviors and Complementary and Alternative Medicine Use: Integrated Wellness Joelle B. Karlik, Elena J. Ladas, Deborah H. Ndao, Bin Cheng, YuanYuan Bao, Kara M. Kelly Correspondence to: Kara M. Kelly, MD, Columbia University Medical Center, 161 Fort Washington Avenue, 7th floor, New York, NY 10032 (e-mail: kk291@ columbia.edu).
Background
Conventional medicine, lifestyle modification, and complementary and alternative medicine (CAM) are potential strategies to decrease the risk of late effects in pediatric cancer survivors. This study aimed to compare the characteristics and usage patterns of CAM and lifestyle therapies among survivors of childhood cancer.
Methods
We report the results of a cross sectional survey comparing usage patterns of CAM and lifestyle therapies among childhood cancer survivors. CAM therapies were defined by NCCAM classifications and lifestyle therapies were defined as dietary changes, conventional supplements with dietary reference intake values, and exercise.
Results
One hundred fifty-five (95%) patients approached in person and 45 (34%) patients approached by mail consented to participate. Sixty-eight used at least one lifestyle therapy and 58% used at least one CAM therapy. CAM users had 4.7 times the odds of using lifestyle therapies than non-CAM users (P < .0001); the odds of using dietary change and conventional supplements was greater in CAM users than non-CAM users (odds ratio [OR] = 3.55, P < .0001 and OR = 4.80, P < .0001 respectively). Use of the top three CAM therapies was associated with overall lifestyle therapy use (OR = 12.52 and P < .0001, OR = 7.071 and P = .0004, and OR = 2.925 and P = .0089 for juicing, yoga/movement, and touch therapies, respectively). Lifestyle therapies and CAM had similar perceived efficacy (92%–90%, respectively).
Conclusions
This data reports a strong association between CAM and lifestyle therapies and may identify a population with commitment to general wellness. Use of one therapy may promote use of other therapies and this potential synergistic relationship can be targeted in future interventions.
J Natl Cancer Inst Monogr 2014;50:323–329
Survivors of childhood cancer often experience physical and psychological long-term complications (late effects) due to the necessary treatment for cancer. Multiple surveys have found that the majority of survivors of childhood cancer practice unhealthy or risky lifestyle behaviors (1–5) that may contribute to certain late effects including metabolic syndrome, osteoporosis, and dyslipidemia. Conventional medicine, healthy lifestyle behaviors, and complementary and alternative medicine (CAM) provide various modalities to decrease the risk of these late effects or to treat existing late effects in these populations. New strategies that promote healthy lifestyle practices may decrease unhealthy behaviors and the risk of developing late effects that may be accelerated by unhealthy behaviors among cancer survivors. The National Center for Complementary and Alternative Medicine (NCCAM) has highlighted the potential role of CAM in promoting healthy lifestyle behaviors in its most recent strategic objectives for 2011–2015 (6). Different strategies may be used in concert with conventional treatments to address a similar concern; for example, meditation and exercise may be used simultaneously to address anxiety in a pediatric cancer survivor. In addition,
a commitment to overall wellness in some CAM users has been described (7–9) and may also extend to lifestyle behaviors as well. However, NCCAM describes a lack of research on this subject and an aim to translate previously measured associations between CAM and healthy lifestyle behaviors into successful lifestyle interventions. Initial research has suggested that adult and geriatric CAM users may have an increased use of healthy lifestyle behaviors and a strong focus on overall wellness. Analyses of data from the National Health Interview Study (NHIS) data, 2002 and 2007, found that adult CAM users were more likely to use exercise and less likely to be obese than adults who did not use CAM (7,10). Associations of CAM with exercise (7,10–13), higher vegetable intake (12,14), lower fat or lipid intake (12,14), and smoking cessation or decreased smoking (10,11,13) have been reported in adults or geriatric populations. Pediatric CAM modalities in the cancer survivor population are often used to decrease stress and promote general health and healing (15), goals that can also be targeted with healthy lifestyle behaviors. However, pediatric research in concurrent CAM and healthy lifestyle behaviors is limited and associations between the two modalities have not been investigated (15–16).
Journal of the National Cancer Institute Monographs, No. 50, 2014 323
In this study, we sought to compare the characteristics and usage patterns of CAM and lifestyle therapies among survivors of childhood cancer. We hypothesized that CAM use supports the adoption of healthy lifestyle behaviors in survivors of childhood and adolescent cancer.
Methods Study Respondents Study respondents were childhood cancer survivors between the age of 2 and 33 at time of survey and had completed the prescribed cancer treatment for at least 3 months. Respondents were contacted during a routine scheduled appointment as part of the standard of care at the Herbert Irving Child and Adolescent Oncology Center, Columbia University Medical Center (CUMC) or by mail. Informed consent was obtained from all patients, parents, or legal guardians. For respondents under the age of 18, the parent or legal guardian was approached for participation. Assent was obtained from children 7 years of age and older. The CUMC Institutional Review Board approved this study. Administration of the survey occurred between June 2005 and July 2008. Survey Instrument and Methods Interviews were conducted using a modified version of a survey previously described in Kelly et al. (16); adaptations were made for survivors of child and adolescent cancer. Interviewers were not involved in the medical care of the patient and administered the survey in-person, over the phone, or through the mail. The survey included demographic information, CAM and lifestyle therapies used, purpose and referral for use, and communication with physician about use. Clinical information was collected from medical charts. Data from completed surveys were entered into a database, open-ended questions were thematically coded and categorized based on responses, and the data was checked for accuracy. Specific CAM therapies were categorized based on NCCAM’s classifications: biologically based therapies (e.g., herbal or botanical remedies; vitamins, minerals, and other natural products; juicing for medicinal purposes; ointments or creams derived from herbal or nutrition supplements), manipulative and body-based therapies (e.g., chiropractor; massage/body work; movement therapies), mind-body therapies (e.g., aromatherapy; imagery; yoga; acupuncture), energy-based therapies (e.g., reiki; qi-gong) and whole medical systems (e.g., homeopathy; Chinese medicine). Lifestyle therapies were distinguished as the adoption of more conventionally accepted healthy behaviors including dietary changes (e.g., increasing fruits and vegetables; eliminating fried foods), conventional supplements (e.g., multivitamin; calcium), and exercise practices (e.g., jogging; karate). Conventional supplements were defined as any supplement with a dietary reference intake (DRI) and included multivitamins, vitamin A, calcium and vitamin D, vitamin E, potassium, vitamin C, B vitamins, selenium, and zinc. Reasons for use were classified based off previous NHIS categories of general wellness (general health and healing, fitness and overall strengthening, immune support, mental and emotional health, relaxation/stress management, fatigue/energy, and improve nutrition) and symptom management [cancer prevention, detoxification, 324
pain, skin/hair, nausea, weight loss, weight gain, rehabilitation, insomnia/sleep, loss of appetite, gastrointestinal relief, concentration/attention, other (7)]. Sources of referral were categorized into three categories: biomedical provider (doctor, nurse, speech therapist, PT, pharmacist, dentist, nutritionist, etc.), integrative provider (herbalist, massage therapist, acupuncturist, Reiki master, etc.), and other sources of information (self, parents, other family members, friends, neighbors, media outlets, other). Statistical Analysis SAS computer program (SAS 9.2) was used for analysis. Demographic information was summarized as mean and standard deviation for continuous variables and count and percentage for categorical variables for all the subjects. The demographic information was compared between CAM users/non-CAM and lifestyle/non-lifestyle users using either a two-sample t-test for a continuous variable and a Chi-square test or a Fisher’s exact test for a categorical variable. Associations between CAM and healthy lifestyle behavior use were examined using a Chi-square or Fisher’s exact test. Since treatments may have been used for multiple indications or multiple treatments may have been used for the same indication, survey items concerning treatment use were analyzed by overall therapy category and individual therapy type.
Results Demographics One hundred fifty-five (95%) patients approached in person and 45 (34%) patients approached by mail consented to participate in the study, which resulted in 100 males (51%) who had completed the interview. Of the three patients that did not complete the survey, one patient relapsed and two patients were lost to follow-up. Sixty percent of surveys were completed by the parent (n = 118), 39% were completed by patients (n = 76), and 2% were completed by grandparents or guardians (n = 3). No association was found between respondent and use of lifestyle therapies or CAM therapies. The average age of survey respondent was 14.5 years (standard deviation [SD] = 6.2 years). Fifty-three percent of patients identified themselves as a non-white ethnicity (n = 105). The demographic characteristics of users and non-users of CAM and lifestyle therapies are presented in Table 1. Overall Use of CAM and Lifestyle Therapies Fifty-eight percent (n = 115) of survey participants used at least one CAM therapy and 68% (n = 134) used at least one healthy lifestyle behavior. The most popular CAM therapies included biologically based therapies (42%), mind-body therapies (30%), manipulative and body-based therapies (27%), energy healing therapies (8%), and whole medical systems (3%). Forty-eight percent (n = 95) of survey respondents used dietary modification, 45% (n = 88) used conventional supplements, and 21% (n = 42) used exercise. Predictors of CAM and Lifestyle Behaviors Male gender and increased parental education were significantly associated with use of lifestyle behaviors (odds ratio [OR] = 2.13, P = .0148 [95% confidence interval (CI) = 1.15–3.93]; risk difference [RD] = 1.09, P = .0395 [95% CI = 1.004–1.19], respectively). Journal of the National Cancer Institute Monographs, No. 50, 2014
No other demographic variables were associated with overall use of lifestyle or CAM behaviors. Ninety-four participants used both CAM and lifestyle therapies, accounting for 48% of the overall survey population, 82% of CAM users, and 70% of lifestyle users. The odds of using a lifestyle therapy among CAM-users was 4.7-fold higher compared to non-CAM users (P < .0001, 95% CI = 2.48–8.93). The majority of users of CAM (65%) also adopted healthy dietary changes, 59% (n = 68) used conventional supplements, and 25% (n = 29) adopted an exercise regimen. The odds of overall dietary change or conventional supplement use were also greater in CAM users compared to non-CAM users (OR = 3.55 [P < .0001, 95% CI = 1.94–6.47];
OR = 4.80 [P < .0001, 95% CI = 2.40–8.39], respectively). CAM use was also associated with the two most popular dietary changes, increasing fruit or vegetable intake and decreasing fried, junk, or fast food, compared to non-CAM users (OR = 2.28 [P = .011, 95% CI = 1.21–4.70]; OR = 4.28 [P = .0026, 95% CI = 1.56–11.71], respectively). However, there was no significant difference found between the odds of exercise between CAM and non-CAM users as the prevalence of exercise among CAM users and the overall study population was nearly equivalent (25% and 21%, respectively). Table 2 compares reasons for use, sources of referral, perceived efficacy, and disclosure rate for overall CAM therapies and healthy lifestyle behaviors. For both CAM therapies and healthy
Table 1. Demographic characteristics* Characteristic Gender Female Male Patient race/ethnicity Black Hispanic White Asian Other Diagnosis Leukemia/lymphoma Brain tumor Solid tumor Other Parent school years completed Time from treatment completion to survey, y
All, No. (%) (N = 197)
No CAM use, No. (%) (N = 82)
CAM use, No. (%) (N = 115)
P
No lifestyle use, No. (%) (N = 63)
Lifestyle use, No. (%)
.86 97 (49) 100 (51)
41 (50) 41 (50)
56 (49) 59 (51)
21 (11) 66 (33) 92 (47) 5 (2) 13 (7)
12 (15) 26 (32) 39 (47) 1 (1) 4 (5)
9 (8) 40 (35) 53 (46) 4 (3) 9 (8)
110 (56) 23 (12) 59 (30) 5 (2) 14.5 ± 3.6
50 (61) 7 (8) 22 (27) 3 (4) 14.1 ± 3.6
60 (52) 16 (14) 37 (32) 2 (2) 14.7 ± 3.5
4.5 ± 4.0
4.6 ± 4.1
4.4 ± 3.9
P .0148†
39 (62) 24 (38)
58 (43) 76 (57)
9 (14) 21 (33) 30 (48) 1 (2) 2 (3)
12 (9) 45 (34) 62 (46) 4 (3) 11 (8)
.24
31 (49) 7 (11) 21 (33) 4 (6) 13.7 ± 4.0
79 (59) 16 (12) 38 (28) 1 (1) 14.8 ± 3.3
.0385†
.94
3.9 ± 4.9
3.5 ± 4.3
.3658
.43
.8594
.39
.1113
* The denominators for statistics shown exclude persons with unknown lifestyle information. CAM = complementary and alternative medicine. † P < .05.
Table 2. Characterization of overall complementary and alternative medicine (CAM) and lifestyle use Reasons for use* General wellness Symptom management Referral source† Conventional provider Integrative provider Other sources Perceived effectiveness Not effective Somewhat Very effective Do not know Disclosed use* Yes No Do not know
Overall CAM therapies, No. (%)
Overall lifestyle therapies, No. (%)
284 (59) 194 (41)
193 (73) 73 (27)
44 (11) 86 (22) 266 (67)
75 (28) 28 (11) 162(61)
13 (4) 112 (30) 228 (62) 15 (4)
8 (3) 77 (29) 160 (60) 20 (8)
191(51) 179 (48) 1 (1)
220 (66) 75 (34) —
* P < .05. † Conventional provider: physician, nurse, speech therapist, physical therapist, pharmacist, dentist, nutritionist, etc. Integrative provider: massage therapist, acupuncturist, Reiki master, etc. Other sources: self, parents, other family members, friends, neighbors, media outlets, etc.
Journal of the National Cancer Institute Monographs, No. 50, 2014 325
lifestyle behaviors, the majority of therapies were initiated after completion of cancer treatment. Both lifestyle and CAM therapies had comparable perceived positive efficacy (90% and 92%, respectively). A larger proportion of CAM therapies were referred by an integrative provider and a larger proportion of healthy lifestyle behaviors were referred by a biomedical provider. Healthy lifestyle behaviors had higher odds of being used for general wellness compared to CAM therapies (OR = 1.81 [P = .0003, 95% CI = 1.30–2.51]), but the majority of CAM therapies were relied upon for general wellness as well. Healthy lifestyle behaviors had significantly greater odds of being disclosed to physicians compared to CAM therapies (OR = 1.71 [P = 0.0012, 95% CI = 1.23–2.38]). Associations Between Lifestyle and CAM Therapies Table 3 presents the significant associations between lifestyle and CAM therapies. The most common CAM therapies were juicing, yoga/movement therapies, and touch therapies, and use of these were also associated with overall healthy lifestyle behaviors (OR = 12.52 [P < .0001, 95% CI = 2.92–53.70]; OR = 7.07 [P = .0004, 95% CI = 2.08–24.00]; OR = 2.93 [P = .0089, 95% CI = 1.28–6.70], respectively). The three most frequently used CAM therapies were significantly associated with the majority of lifestyle therapies. A high odds ratio was observed between herbal supplement use and use of conventional supplements (OR = 2.43, P = .0342, 95% CI = 1.05–5.62). However, no significant associations were observed between exercise and touch therapies and conventional supplements and juicing. Table 4 compares reasons for use, sources, of referral, perceived efficacy, and disclosure rate for specific CAM therapies and healthy lifestyle behaviors. The characterization of specific therapies was largely similar to the previous characterization of overall CAM use and healthy lifestyle behaviors in that there was high perceived efficacy and primarily used for general wellness.
Discussion This is the first study to explore the association of the use of CAM with healthy lifestyle behaviors among an ethnically diverse population at high risk for lifestyle-related chronic diseases. We observed a high prevalence of the combination of CAM and healthy lifestyle behaviors and repeated associations between the two types of therapies in pediatric cancer survivors. This pattern remained when looking at individual therapies as well. Similarities between
lifestyle behaviors and CAM therapies included highly perceived efficacy and use for general wellness. While the reported associations between CAM and healthy lifestyle therapies appear strong and occur on overall and specific therapy levels, the results do not elucidate the nature of such a relationship. These findings suggest that this pediatric survivor population holds a strong overall commitment to wellness. However, investigation into a causal pathway between CAM therapies and healthy lifestyle behaviors is warranted (6). The use of one therapy may promote use of other therapies but the directionality of these associations is unknown. Previous research has described two separate CAM populations, health promotion or symptom relief (7,8,17,18), which our study supports. Cancer-specific CAM usage reasons, including reduction of relapse and subsequent cancer prevention, were included in these two separate populations for our analysis (see “Methods”). However, lifestyle therapy use between these CAM populations may vary, including cancer survivors. For example, “health promotion” CAM users may be more likely to use lifestyle behaviors than “symptom relief” CAM users. Further research into healthy lifestyle behavior use in these different groups of CAM users may better define the populations and clarify the associations between each group and healthy lifestyle behaviors. Compared to healthy controls, cancer survivors may require alternative interventions due to their targeted CAM uses. Better characterization may also increase the likelihood of successful interventions to increase lifestyle behavior use. Multiple studies have found that pediatric cancer survivors continue to practice unhealthy lifestyle behaviors, especially in the adolescent population (2–5). In our study, the majority of both CAM and lifestyle therapies were initiated after treatment completion, possibly identifying a “teachable moment.” “Teachable moments” have been described at the time of cancer diagnosis previously (19); our data suggests that a second “teachable moment” may occur during cancer survivorship as well. Some studies in adolescent and adult cancer survivor populations challenge this pattern (2,20). Further research into the period after cancer treatment completion may clarify the optimal timing for a healthy lifestyle behavior intervention. For some survivors, education on CAM therapies from reliable practitioners may be a strategy to promote general wellness and lead into healthy lifestyle behaviors. The majority of referrals for both CAM and healthy lifestyle behaviors were not obtained by a professional provider. Previous studies have shown that adult cancer survivors cite referrals from
Table 3. Associations between specific complementary and alternative medicine (CAM) therapies and healthy lifestyle behaviors* CAM therapy
Healthy lifestyle behavior
OR
P
95% CI
Juicing Yoga/movement therapies Touch therapies Yoga/movement therapies Juicing Touch therapies Yoga/movement therapies Touch therapies Juicing
Dietary change Dietary change Conventional supplement Conventional supplement Exercise Dietary change Exercise Exercise Conventional supplements
9.33 3.84 2.94 2.93 2.76 2.42 2.33 2.05 1.79
