The use of complementary and alternative medicine (CAM) has been growing rapidly in the U.S. in recent years. The proportion of adults reporting the use of at least one CAM therapy during the previous year increased from 33.8% in 1990 to 42.1% in 1997 (1). Data from the 2002 National Health Interview Survey (NHIS) revealed that close to two-thirds of U.S. adults had used at least one CAM therapy during the previous year (2). A recent study using 2002 NHIS data showed that about one-half of all adults with diabetes were CAM users (3).

The main reasons for the rising popularity of CAM range from the actual/perceived inadequacies of conventional treatments to the desire for more autonomy in treatment decisions (3,4). Interestingly, CAM use is rising while at the same time conventional medicine has become less affordable (5). The purpose of this study is to analyze the relation between the affordability of conventional health care and the use of CAM by adults with diabetes.

The 2002 NHIS is a nationally representative survey of the civilian noninstitutionalized U.S. population. The survey includes demographic, socioeconomic, health, and health care utilization information on a sample of 31,044 adults. The 2002 NHIS included a CAM supplement with detailed information on the use of 17 CAM therapies (6). Our final sample included 2,142 adults who had been told by a doctor or other health care professional that they had diabetes. We focused on the use of at least 1 CAM therapy and on the individual use of 10 different CAM modalities. We only studied CAM modalities used by at least 1% of adults with diabetes in the sample (i.e., prayer and spiritual healing, herbal treatments, relaxation, chiropractic care, yoga/tai chi/qigong, massage, special diets, megavitamins, homeopathy, and acupuncture).

We created a dichotomous variable to capture whether respondents delayed or did not get needed conventional medical care because of cost (i.e., answering yes to one or both of these questions: “During the past 12 months, has medical care been delayed for [person] because of worry about the cost?” and “During the past 12 months, was there any time when [person] needed medical care, but did not get it because [person] couldn't afford it?”) (7). We then used Pearson χ2 tests to analyze whether there were differences in CAM utilization that were related to delaying or not getting needed medical care because of cost.

For each CAM modality, we also estimated the average marginal effect of conventional health care access difficulties on CAM utilization based on a logistic regression adjusted for health insurance coverage status, education, age, sex, marital status, self-reported health status, ethnicity/race, and family income (8). All of the estimations were carried out using Stata, version 9.2, taking into account the complex survey design of the 2002 NHIS (9).

Table 1 shows that 70.48% of adults with diabetes used at least one CAM modality within the past year. CAM utilization rates were particularly high for prayer (61.34%), herbal treatments (15.09%), relaxation techniques (11.79%), and chiropractic care (6.57%). Except for megavitamins, CAM utilization rates were higher for adults with diabetes that delayed or did not get needed medical care because of cost than for those reporting no delays. The differences in CAM utilization rates associated with delays in getting conventional medical care were statistically significant for the use of at least one CAM modality (77.04 vs. 69.44%): prayer (70.56 vs. 59.89%), herbal treatments (19.86 vs. 14.34%), relaxation techniques (18.69 vs. 10.70%), and acupuncture (2.97 vs. 1.07%).

Table 1 also reports the average marginal effects of delayed/postponed care on CAM use. The marginal effects were estimated from a logistic regression of CAM use adjusted for the covariates presented above. Adults with diabetes who reported delaying or not getting needed medical care because of cost were 7.00 percentage points more likely to have used at least one CAM modality within the past year compared with those not reporting any delays (P = 0.085). The marginal effects were positive for 9 of 10 analyzed CAM therapies, and they were relatively large and statistically significant for prayer (11.25 percentage points, P = 0.006) and relaxation techniques (8.48 percentage points, P = 0.014).

We found that adults with diabetes who delayed or did not get needed conventional medical care because of cost were more likely to report the use of at least one CAM modality within the past year compared with those reporting no cost-related difficulties in receiving care. These differences were present for 9 of 10 studied CAM therapies, and they were particularly important for prayer, herbal treatments, and relaxation techniques.

The results presented here suggest that when conventional health care becomes unaffordable, adults with diabetes resort to CAM to meet their unmet health care needs. An interesting finding is that education was positively related to the use of most CAM modalities. This suggests that CAM may be an integral component of diabetes management for those with better adherence to treatment regimes (10). Close to 89% of CAM users with diabetes reported that CAM had been important in maintaining their health compared with 79% of CAM users without diabetes. Approximately 52% of CAM users with diabetes had told their doctors about their use of CAM compared with 39% of CAM users without diabetes.

Several years of rising health care costs are likely to have forced many adults with diabetes to either delay or postpone health care or to resort to CAM (5). This should be a cause for concern because the clinical effectiveness of many CAM therapies favored by people with diabetes have not been fully established (11). Diabetes is a chronic health condition that requires careful management and appropriate access to the health care system to prevent related complications (12). As the use of CAM continues to grow because of rising costs, it is important that physicians are aware about the use of CAM by their patients to avoid potential risks.

Table 1—

CAM use by cost-related health care access and marginal effects of access based on logistic regression model of CAM use among adults with diabetes

AllDelayed or did not get needed medical care because of cost
Marginal effects
YesNo
Used at least one CAM therapy 70.48 77.04 69.44* 7.00 (−0.95 to 14.96)† 
Prayer and spiritual healing for own health 61.34 70.56 59.89‡ 11.25 (3.16 to 19.35)‡ 
Herbal treatments 15.09 19.86 14.34* 5.59 (−1.20 to 12.37) 
Relaxation 11.79 18.69 10.70‡ 8.48 (1.68 to 15.28)* 
Chiropractic care 6.57 7.61 6.41 5.45 (−2.31 to 13.39) 
Yoga/tai chi/qigong 1.88 2.56 1.78 −0.36 (−2.94 to 2.24) 
Massage 3.15 4.12 3.00 2.38 (−3.57 to 8.34) 
Special diets 3.12 4.81 2.85 3.87 (−1.91 to 9.65) 
Megavitamins 2.91 2.49 2.97 0.91 (−2.46 to 4.29) 
Homeopathy 1.50 2.05 1.41 1.29 (−1.18 to 3.77) 
Acupuncture 1.33 2.97 1.07† 1.04 (−1.36 to 3.45) 
AllDelayed or did not get needed medical care because of cost
Marginal effects
YesNo
Used at least one CAM therapy 70.48 77.04 69.44* 7.00 (−0.95 to 14.96)† 
Prayer and spiritual healing for own health 61.34 70.56 59.89‡ 11.25 (3.16 to 19.35)‡ 
Herbal treatments 15.09 19.86 14.34* 5.59 (−1.20 to 12.37) 
Relaxation 11.79 18.69 10.70‡ 8.48 (1.68 to 15.28)* 
Chiropractic care 6.57 7.61 6.41 5.45 (−2.31 to 13.39) 
Yoga/tai chi/qigong 1.88 2.56 1.78 −0.36 (−2.94 to 2.24) 
Massage 3.15 4.12 3.00 2.38 (−3.57 to 8.34) 
Special diets 3.12 4.81 2.85 3.87 (−1.91 to 9.65) 
Megavitamins 2.91 2.49 2.97 0.91 (−2.46 to 4.29) 
Homeopathy 1.50 2.05 1.41 1.29 (−1.18 to 3.77) 
Acupuncture 1.33 2.97 1.07† 1.04 (−1.36 to 3.45) 

Data are percentages or percentage points (95% CI).

*

P < 0.05;

†

P < 0.10;

‡

P < 0.01.

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This publication was made possible by grants R21 AT002857-01A1 and 3 R21 AT002857-01A1S1 from the National Center for Complementary and Alternative Medicine, National Institutes of Health.

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Published ahead of print at http://care.diabetesjournals.org on 22 May 2007. DOI: 10.2337/dc07-0433.

The contents of this study are solely the responsibility of the authors and do not necessarily represent the official views of the National Center for Complementary and Alternative Medicine, National Institutes of Health.

A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C Section 1734 solely to indicate this fact.

DIABETES CARE
2007