Use of Five Complementary Health Modalities Relevant to Lifestyle Medicine: A 2020 Survey of Northern California Adults Aged 35-79 years

Abstract

Introduction

Complementary health (CH) modalities can be used as part of a Lifestyle Medicine (LM) approach to preventing and managing chronic conditions.

Methods

This cross-sectional study used data for respondents to the 2020 (N = 6,715) and 2014/2015 (N = 11,112) cycles of a Northern California health plan member survey to estimate use in 2020 of five CH modalities relevant to LM: vegetarian/vegan diet, mind/body stress management techniques (MBSM), yoga/Pilates, massage therapy, and prayer/spiritual practice. Use was estimated by sex and racial/ethnic group (White, Black, Latino, Asian/PI)) for ages 35-64 and 65-79 years and for adults 35-79 years with diabetes, hypertension, heart disease, fair/poor sleep quality, and chronic stress. CH use in 2020 was compared to 2014/2015.

Results

In 2020, 53% of adults used ≥1 of these CH modalities, including 8.4% vegetarian/vegan diet, 25.8% MBSM, 23.7% prayer/spiritual practice, 16.5% yoga/Pilates, and 17.7% massage. Sex, age group, and racial/ethnic differences were seen in use of most CH modalities, and CH modality use varied by health condition. Significant increases from 2014/2015 to 2020 were seen in use of MBSM and yoga/Pilates, vegetarian/vegan diet, and prayer/spiritual practice.

Conclusion

There is substantial opportunity to increase use of CH modalities within a LM approach to preventing and managing chronic health conditions.

Keywords

lifestyle medicine complementary health integrative health yoga plant-predominant diet vegetarian diet stress reduction spiritual practice mind-body medicine mindfulness meditation

“Our study is among the first contemporary studies to estimate the use of CH modalities across different chronic health conditions.”

Introduction

There is growing interest among healthcare providers and patients in “whole person” health, defined by the National Center for Complementary and Integrative Health as “helping individuals, families, communities, and populations improve and restore their health in multiple interconnected domains—biological, behavioral, social, environmental—rather than just treating disease.”¹ The whole person approach to healthcare aligns with the growing specialty field of Lifestyle Medicine, which the American College of Lifestyle Medicine describes as the use of lifestyle interventions such as whole food, plant-predominant dietary lifestyle, regular physical activity, restorative sleep, stress management, avoidance of risky substances, and positive social connections as the primary therapeutic modalities for prevention, treatment, and reversal of chronic health conditions.² The older but continually evolving field of complementary and integrative health (CH), which uses conventional Western medicine (e.g., medication, surgery, physical rehabilitation, and psychotherapy) together with non-mainstream therapies (e.g., special diets, mindfulness meditation, acupuncture, massage therapy, and yoga) in a coordinated way, also aligns with a whole person approach to treat and prevent disease,¹ also aligns with a whole person approach to healthcare. Many CH modalities can effectively be used to address one or more of the six pillars of Lifestyle Medicine, and successful use of individual CH modalities may also serve as a bridge to future adoption of the lifestyle changes recommended by the American College of Lifestyle Medicine. It has now been more than two decades since the 2012 National Ambulatory Medical Care Survey (NAMCS PII) found that more than half of office-based physicians had recommended at least one CH approach to their patients within a 12-month period.³ However, the extent to which contemporary populations utilize these modalities is less clear.

In this article, we focus on five CH modalities that we feel have the most direct relevance to the six pillars of Lifestyle Medicine (Table 1). Vegetarian and vegan diets are, by definition, plant-predominant eating patterns that closely relate to the pillar of nutrition. Mind-body stress management (MBSM) includes deep breathing and meditation mindfulness techniques that not only help with stress management but also can improve quality of sleep.^4,5 Yoga and Pilates are physical activities and have been associated with reduced stress⁶ and better sleep quality.^7,8 Massage has been shown to help with stress reduction⁹ and sleep restoration in certain populations.¹⁰ Prayer/spiritual practice can reduce stress,¹¹ has been shown to have positive effects on health,^12,13 and when it occurs in the context of an organized congregation or group, it can also increase feelings of social connectedness.¹⁴ Religiosity and spirituality are also associated with lower use of risky substances.¹⁵

Table 1.

Complementary Health Modalities Relevant to Lifestyle Medicine Pillars.

Lifestyle Medicine Pillar	Complementary Health Modality
Lifestyle Medicine Pillar	Vegetarian or vegan diet	Mind/body stress management techniques	Prayer/spiritual practice	Yoga or pilates	Massage therapy
Nutrition	X
Physical activity				X
Stress management		X	X	X	X
Restorative sleep		X	X	X	X
Social connection			X
Avoidance of risky substances		X	X

X indicates intersectionality of Lifestyle Medicine pillar and complementary health modality.

Each of these five CH modalities have been shown to positively impact chronic conditions. For example, vegetarian and vegan diets have been linked to significantly lower incidence of cancer,¹⁶ and plant-predominant diets may play a major role in stabilizing or even reversing type 2 diabetes and cardiovascular disease.^17,18 MBSM interventions have been shown to reduce blood pressure.¹⁹ The practice of yoga has been studied as an effective adjunctive therapy for hypertension²⁰ and diabetes,²¹ and use of Pilates-based exercise protocols has been shown to reduce glycated hemoglobin in patients with type 2 diabetes.²² Furthermore, a combination of yoga, vegetarian diet, and meditative practices has been shown to significantly improve various parameters associated with metabolic syndrome, including waist circumference, blood pressure, hemoglobin A1c, and lipid markers.²³ Massage therapy, used in combination with antihypertensive medications, has been shown to reduce systolic blood pressure significantly more than medication alone.²⁴ However, it is important to note that while these CH modalities can be used to address many pillars of Lifestyle Medicine, the American College of Lifestyle Medicine views the practice of Lifestyle Medicine as the foundation of a whole person healthcare delivery system to be utilized as a primary, not complementary, approach to preventing, treating and reversing disease.

While several U.S. studies have estimated the use of CH modalities (previously called complementary and alternative medicine or CAM) among adults in the late 1990s and early 2000s, information about the use of CH modalities in contemporary community-dwelling U.S. adult populations remains limited,^25-27 particularly in healthcare settings. The aims of our study were: to estimate prevalence of use of these five CH modalities in a community-dwelling adult health plan population in 2020, including those with select chronic health conditions; to examine variation in CH modality usage by demographic group; and to learn whether use of CH modalities has increased over time, given the growing interest in holistic health and therapeutic lifestyle interventions.

Methods

Setting and Study Population

Kaiser Permanente in Northern California (KPNC) is an integrated healthcare delivery system that provides primary and specialty health care to a sociodemographically diverse health plan membership that includes over three million adults who mostly reside in the Greater San Francisco Bay, Sacramento, Silicon Valley, and Central Valley areas of Northern California. The KPNC adult membership is similar to the non-Medicaid insured adult population of Northern California with regards to sociodemographic and health characteristics.²⁸

Data Source

We used data for KPNC members aged 35-79 years who responded to the 2014/2015 (N = 11,112) or 2020 (N = 6,715) cycles of the KPNC Member Health Survey (MHS). The MHS is a self-administered survey conducted with an age-sex stratified random sample of adults aged 25-90 who were health plan members during at least the fourth quarter of the preceding year. The 2020 survey cycle used a sample half as large as the 2014/2015 cycle. The MHS, which is conducted in English only, collects self-reported information about sociodemographic and health-related characteristics. More information about the MHS can be found in an earlier publication.²⁹

Study Variables

Complementary Health Modalities

The MHS included a checklist question which asked whether during the past 12 months the respondent had used any of the following methods to help prevent or manage their own health problems. In this study, we focused on the following five CH modalities: vegetarian or vegan diet; deep breathing, mindfulness meditation, or other mind-body stress management (MBSM) techniques; prayer or spiritual practice done by the individual; massage therapy (massage); and yoga or Pilates. Because many MBSM techniques were derived from prayer and spiritual practice, especially meditation, we also created a composite variable to capture use of MBSM and/or prayer/spiritual practice (MBSM/PSP).

Chronic Health Conditions

Using combined responses from two checklist questions, respondents were identified as having diabetes (other than only during pregnancy), hypertension, and/or heart disease (e.g., heart attack, angina, blocked artery, atrial fibrillation, congestive heart failure) if in the past 12 months they reported having that condition or using medication or a special diet for that condition. Separate questions were used to identify people with fair or poor sleep quality (response of fair, poor, or very poor to “How would you rate the usual quality of your sleep?”) and chronic stress or tension (response of “much of the time” or “most of the time” to “During the past 12 months, how often have you felt very stressed, tense or anxious?”).

Sociodemographic Characteristics

Sociodemographic characteristics derived from the self-reported survey data included sex (male/female); age at time of the survey; racial/ethnic group (non-Hispanic White (White), African American/Black (Black), Latino, Asian or Native Hawaiian/Pacific Islander (Asian/PI), or other); and educational attainment (≤ high school diploma, some college or associate degree, or ≥ bachelor’s degree).

Statistical Analysis

For both survey cycles, respondents were assigned post-stratification weighting factors so that the analytic sample, after weighting, would reflect the age-sex-racial/ethnic (White, Black, Latino, Asian/PI, other) composition of the 2019 KPNC membership aged 35-79 years with English as their written language preference. We used SAS Proc Surveyfreq to estimate prevalence and 95% confidence intervals (CI) for each of the five CH modalities (vegetarian or vegan diet; MBSM techniques; prayer/spiritual practice; yoga or Pilates; and massage) and MBSM/PSP among four age-sex groups overall and by race/ethnicity. Modified log-Poisson regression models were conducted to examine differences in prevalence of CH modality use by age (65-79 vs 35-64 years), sex (female vs male), and racial/ethnic (Black, Latino, Asian/PI vs White) groups after adjusting for demographic covariates.

To compare prevalence of the five CH modalities in 2014/2015 to 2020, we created normalized weights for the 2014/2015 survey that weighted respondent data to the same age-sex-racial/ethnic distribution as the 2020 weighted sample. We then produced prevalence estimates for the CH modalities in 2014/2015. To evaluate whether significant changes had occurred between 2014/2015 and 2020, for each survey cycle, we produced estimated counts of adults who used and who did not use each of the five CH modalities for each age-sex group using weighted data. Chi-square tests (using the VassarStats website statistical calculator (https://vassarstats.net/index.html) were then conducted to compare findings for each CH modality between MHS survey years.

All results reported are based on weighted survey data, and all differences mentioned in the results are significant at P < 0.05 unless otherwise noted.

Results

The 2020 study cohort (N = 6,715) was comprised of 1379 men and 1570 women aged 35-64 years (middle-aged), and 1805 men and 1961 women aged 65-79 years (older-aged). Table 2 provides characteristics of the study population overall and by age-sex subgroups based on weighted survey data. Within the overall population, the majority were White (53.7%) and mostly college-educated (84.8%, with 55.9% having a bachelor’s degree or higher). Approximately 90% of the study population was in good health, with 52.3% of adults considering their health to be very good or excellent. Overall, 12.2% of adults reported diabetes, 31.4% hypertension, 6% heart disease, 46.4% fair or poor quality sleep, and 19.0% chronic stress or tension. However, within both age groups, men were more likely than women to have chronic cardiovascular conditions, and women were more likely to have chronic stress. Comparing across age groups, middle-aged men and women were more likely than their older-aged counterparts to be non-White, to have a bachelor’s degree or higher and to be in very good/excellent health and were less likely to have diabetes, hypertension, and/or heart disease. Women in the middle-aged group were also more likely than older-aged women to have chronic stress and fair/poor quality sleep.

Table 2.

Characteristics of the Study Population.

	35-79 years		35-64 years				65-79 years
	All		Male		Female		Male		Female
	Unwtd. N	Wtd. %	Unwtd. N	Wtd. %	Unwtd. N	Wtd. %	Unwtd. N	Wtd. %	Unwtd. N	Wtd. %
Age, mean (std.)	6715	54.9 (11.7)	1379	49.4 (11.0)	1570	49.4 (10.8)	1805	71.0 (2.5)	1961	71.1 (2.7)
Race/ethnicity
White non-Hispanic	4238	53.7	835	50.5^a	949	48.3^a	1207	66.8	1247	66.2
Black	477	7.9	83	7.5	108	8.6	123	6.7	163	8.0
Latino	694	14.0	168	15.9^a	206	15.8^a	146	8.7	174	8.9
Asian/PI	1243	22.8	278	24.6^a	286	25.6^a	312	16.0	367	15.7
Other	63	1.6	15	1.6	21	1.7	17	1.9	10	1.1
Education
≤ High school diploma/GED	1113	15.2	231	15.9	201	12.6^a	304	17.0	377	19.1
Some college (no degree or associate degree)	2097	28.9	371	26.6	449	27.4	569	32.1	708	36.5
Bachelor’s degree or higher	3439	55.9	766	57.5^a	903	60.1^a	918	50.9	852	44.4^b
Overall health status
Very good/excellent	3222	52.3	700	53.0^a	863	55.4^a	773	45.0	886	48.2
Good	2503	37.3	519	38.2	548	35.6	686	38.8	750	38.5
Fair/poor	828	10.4	131	8.8^a	139	9.0^a	288	16.2	270	13.3
Has chronic health condition
Diabetes
No	5686	87.8	1199	87.8	1443	91.8	1385	77.3	1659	85.3
Yes	1025	12.2	178	12.2^a	127	8.2^ab	418	22.7	302	14.7^b
Hypertension
No	3818	68.6	937	72.0	1232	80.0	732	42.6	917	49.3
Yes	2893	31.4	440	28.0^a	338	20.0^ab	1071	57.4	1044	50.7^b
Heart disease
No	6005	93.5	1284	94.6	1529	97.6	1459	81.6	1733	89.1
Yes	706	6.5	93	5.4^a	41	2.4^ab	344	18.4	228	10.9^b
Fair/poor quality sleep
No	3687	53.6	740	54.6	790	50.3	1039	58.2	1118	57.2
Yes	2952	46.4	625	45.4	770	49.7^a	740	41.8	817	42.8
Chronic stress/tension
No	5715	81.0	1144	82.4	1156	73.1	1679	94.0	1736	89.4
Yes	919	19.0	226	17.6^a	403	26.9^ab	97	6.0	193	10.6^b

Unwtd. N: Number of survey respondents in cell prior to weighting; Wtd. %: Percentage of adults with characteristic based on data weighted to the age-sex-racial composition of the health plan membership. Asian/PI: Asian or Native Hawaiian/Pacific Islander.

^aP < .05 compared to 65-79 year age group within same sex after adjusting for racial/ethnic group.

^bP < .05 compared to men within same age group after adjusting for racial/ethnic group.

Use of Complementary Health Modalities in 2020

We estimate that in 2020, 8.4% of adults used a vegetarian or vegan diet, 25.8% MBSM techniques, 23.7% prayer/spiritual practice, 39.8% MBSM/PSP, 16.5% yoga/Pilates, and 17.7% massage therapy, and over half used at least one of these five modalities (Table 3). Middle-aged men and women were more likely than older-aged men and women to have a vegetarian or vegan diet and to use MBSM techniques, yoga/Pilates, and massage. Middle-aged women were less likely than older-aged women to indicate use of prayer/spiritual practice. In both age groups, women were more likely than men to use MBSM techniques, prayer or spiritual practice, and yoga or Pilates. In the middle-aged group, women were more likely than men to follow a vegetarian or vegan diet.

Table 3.

Prevalence of Use of Five Complementary Health Modalities Among Adults Ages 35-79, by Age Group and Sex, 2020.

Complementary health modality	All	35-79 years		35-64 years		65-79 years
Complementary health modality	Wtd. %	Men Wtd. %	Women Wtd. %	Men Wtd. %	Women Wtd. %	Men Wtd. %	Women Wtd. %
Vegetarian or vegan diet	8.4	6.4	10.1^a	7.1	11.7^b	4.4	5.6
MBSM techniques	25.8	20.3	30.6^a	22.3	33.3^b	14.3^c	23.1^bc
Prayer/spiritual practice (PSP)	23.7	18.3	28.6^a	18.5	27.8^b	17.5	30.8^b
MBSM/PSP	39.8	31.8	46.8^a	33.6	48.1^b	26.2^c	43.2^b
Yoga or pilates	16.5	9.8	22.5^a	11.2	25.3^b	5.7^c	14.4^bc
Massage therapy	17.7	13.3	21.6^a	15.0	25.1^b	7.9^c	11.7^bc
≥1 of the 5 CH modalities	53.2	42.8	62.4^a	45.2	65.1^b	35.3^c	54.6^bc

MBSM: Mind/body stress management; CH: Complementary health.

^aP < .01 compared to men after adjusting for racial/ethnic group and age group.

^bP < .01 compared to men in the same age group after adjusting for racial/ethnic group.

^cP < .01 compared to 35-64 age group within same sex after adjusting for racial/ethnic group.

Racial/Ethnic Differences in Use of Complementary Health Modalities

In 2020, we observed several significant racial/ethnic differences in all CH modalities except for massage (Table 4). Compared to White women, Asian/PI women in both age groups were less likely to have used any of the CH modalities. Practice of a vegetarian or vegan diet was less prevalent among middle-aged Black and Latina women than similarly aged White women and more prevalent among older-aged Asian/PI men than White men. Usage of MBSM techniques was less prevalent among Black and Asian/PI than White women in both age groups and less prevalent among Latino compared to White men in the middle-aged group. Use of prayer/spiritual practice for health-related reasons was more prevalent among Black and Latino women and men than White women and men in both age groups and was more prevalent among Asian/PI men than White men in both age groups. MBSM/PSP usage was lower among Asian/PI women compared to White women in the middle-aged group and higher among Black vs White adults in the older-aged group. Among women, use of yoga/Pilates was less prevalent among Black and Asian/PI women in both age groups and Latina women in the older-aged group compared to similarly aged White women. No significant racial/ethnic differences were observed for use of massage therapy. As with the full population, within age and racial/ethnic groups, women were more likely than men to use most of these CH modalities.

Table 4.

Racial/Ethnic Differences in Prevalence of Use of Five Complementary Health Modalities Within Four Age-Sex Groups, 2020.

Complementary health modality	Ages 35-64 years				Ages 65-79 years
Complementary health modality	White Wtd. %	Black Wtd. %	Latino Wtd. %	Asian/PI Wtd. %	White Wtd. %	Black Wtd. %	Latino Wtd. %	Asian/PI Wtd. %
Vegetarian or vegan diet
Men	7.4	4.8	4.8	9.4	3.9	3.2	4.7	7.3^a
Women	14.5^b	5.6^a	7.1^a	11.1	5.7^b	6.0	3.6	6.4
MBSM techniques
Men	25.2	21.9	11.8^a	24.5	14.4	14.2	14.0	15.1
Women	37.9^b	24.6^a	34.0^b	27.5^a	25.2^b	15.2^a	23.7	17.5^a
Prayer/spiritual practice (PSP)
Men	16.5	29.5^a	21.9	17.2	15.0	27.0^a	22.3^a	20.3^a
Women	24.6^b	36.1^a	36.6^a,b	25.7^b	27.9^b	52.9^a,b	39.0^a,b	28.0^b
MBSM/PSP
Men	34.5	41.1	26.9	34.5	25.0	34.4^a	27.0	27.4
Women	50.0^b	44.6	54.0^b	42.9^a,b	42.6^b	58.0^a,b	48.6^b	36.4
Yoga or pilates
Men	11.9	12.9	8.2	11.5	6.5	1.2^a	3.1	6.0
Women	31.5^b	14.6^a	16.1^a,b	22.5^a,b	16.7^b	7.5^a,b	8.3^a	11.5^a,b
Massage therapy
Men	14.3	13.4	17.0	16.6	7.9	9.4	7.8	7.6
Women	27.3^b	20.3	25.0^b	22.6^b	13.0^b	8.4	9.5	9.4
≥1 of the 5 CH modalities
Men	45.3	51.2	39.1	48.2	33.7	40.1	33.4	35.1
Women	69.2^b	57.4	64.5^b	58.9^a,b	55.4^b	59.9^b	53.3^b	47.3^a

Asian/PI: Asian or Native Hawaiian/Pacific Islander; MBSM: Mind/body stress management; CH: Complementary health.

^aP < .05 compared to White adults within same age-sex group.

^bP < .05 compared to men within same racial/ethnic and age group.

Use of Complementary Health Modalities by Adults with Chronic Health Conditions

We examined prevalence of use in 2020 of the five CH modalities relevant to management of selected chronic conditions using a Lifestyle Medicine approach to care. Specifically, we estimated use of vegetarian/vegan diet among adults with diabetes, hypertension, and/or heart disease, and use of MBSM techniques, prayer/spiritual practice, MBSM/PSP, and yoga/Pilates among adults with diabetes, hypertension, heart disease, fair/poor sleep quality, and chronic high levels of stress (Table 5). Vegetarian/vegan diets were being used by <10% of adults with diabetes, hypertension, and/or heart disease. Use of MBSM techniques ranged from 18%–19% for adults with these three chronic conditions to approximately 27% of adults with fair/poor sleep quality and 40% of adults with chronic stress. Prayer/spiritual practice was being used by 23%–30% of adults across all chronic conditions. When we examined use of MBSM techniques and/or prayer/spiritual practice as one category, the prevalence was 34%–37% among adults with diabetes, hypertension, and/or heart disease, 41% of those with fair/poor sleep quality, and 52% of those with chronic stress. Yoga/Pilates use was <10% among adults with diabetes, hypertension, and/or heart disease, but 15%–18% among adults with fair/poor sleep quality and chronic stress.

Table 5.

Prevalence of Use of Five Complementary Health Modalities in 2020 Among Adults With Selected Chronic Health Conditions.

Complementary health modality	Diabetes	Hypertension	Heart disease	Fair/poor sleep quality	Chronic stress
Complementary health modality	Wtd. % (95% CI)	Wtd. % (95% CI)	Wtd. % (95% CI)	Wtd. % (95% CI)	Wtd. % (95% CI)
Vegetarian or vegan diet
All	5.7% (3.6%–7.8%)	4.9% (3.8%–6.0%)	6.9% (4.6%–9.2%)	––	––
Men	6.2% (3.1%–9.2%)	4.2% (2.8%–5.6%)	6.9% (3.8%–10.0%)	––	––
Women	5.1% (2.5%–7.8%)	5.6% (3.9%–7.3%)	6.8% (3.5%–10.2%)	––	––
MBSM techniques
All	19.2% (15.8%–22.6%)	19.3% (17.4%–21.3%)	18.4% (14.7%–22.2%)	26.9% (24.9%–29.0%)	40.0% (36.3%–43.7%)
Men	14.2% (10.2%–18.2%)	14.8% (12.3%–17.4%)	13.9% (9.6%–18.1%)	21.2% (18.3%–24.0%)	36.8% (30.6%–43.0%)
Women	25.8% (20.1%–31.5%)^a	24.3% (21.4%–27.3%)^a	26.0% (19.2%–32.8%)^a	31.7% (28.8%–34.5%)^a	41.8% (37.2%–46.5%)^a
Prayer/spiritual practice
All	27.0% (23.2%–30.7%)	23.4% (21.5%–25.4%)	25.7% (21.4%–30.1%)	24.7% (22.7%–26.7%)	29.8% (26.4%–33.3%)
Men	20.1% (15.6%–24.7%)	17.4% (14.8%–20.0%)	19.7% (14.5%–24.9%)	19.5% (16.7%–22.2%)	24.3% (18.9%–29.8%)
Women	36.0% (29.9%–42.1%)^a	30.2% (27.1%–33.2%)^a	35.6% (28.1%–43.2%)^a	29.0% (26.3%–31.8%)^a	33.0% (28.5%–37.5%)^a
MBSM/PSP
All	36.4% (32.4%–40.4%)	34.2% (31.9%–36.4%)	37.3% (32.6%–42.1%)	40.8% (38.5%–43.0%)	52.8% (49.0%–56.6%)
Men	28.4% (23.4%–33.4%)	26.6% (23.5%–29.6%)	30.1% (24.3%–35.9%)	33.0% (29.7%–36.2%)	46.8% (40.4%–53.2%)
Women	47.0% (40.7%–53.3%)^a	42.7% (39.3%–46.0%)^a	49.2% (41.4%–57.0%)^a	47.2% (44.1%–50.2%)^a	56.3% (51.6%–60.9%)^a
Yoga or pilates
All	6.4% (4.3%–8.6%)	7.8% (6.5%–9.1%)	6.1% (3.9%–8.3%)	15.3% (13.6%–16.9%)	17.5% (14.6%–20.4%)
Men	6.4% (3.3%–9.5%)	5.1% (3.6%–6.7%)	4.8% (2.2%–7.4%)	8.2% (6.3%–10.1%)	9.8% (5.8%–13.9%)
Women	6.5% (3.7%–9.2%)	10.7% (8.7%–12.8%)^a	8.2% (4.4%–12.1%)	21.1% (18.6%–23.6%)^a	22.0% (18.1%–25.9%)^a
Massage therapy
All	11.8% (9.0%–14.7%)	11.0% (9.4%–12.5%)	10.8% (7.8%–13.8%)	17.9% (16.1%–19.7%)	23.6% (20.4%–26.8%)
Men	10.0% (6.8%–13.3%)	9.2% (7.2%–11.3%)	8.3% (5.2%–11.3%)	14.3% (11.8%–16.7%)	16.2% (11.3%–21.1%)
Women	14.3% (9.3%–19.2%)	12.9% (10.5%–15.3%)^a	14.9% (9.0%–20.9%)	20.9% (18.4%–23.5%)^a	27.8% (23.6%–32.0%)^a

Wtd. %: Estimated percentage of adults with this health condition who used complementary health modality based on survey data weighted to the age-sex-racial composition of the health plan membership. MBSM: Mind/body stress management; PSP: Prayer/spiritual practice. –: Not examined. All chronic health conditions are based on self-reported data. Unweighted N’s for men/women: Diabetes: 596/429; Hypertension: 1511/1382; Heart disease: 437/269; Fair/poor sleep quality: 1365/1587; Chronic stress: 323/596.

^aP < 0.05 compared to men after adjusting for racial/ethnic group.

We also examined whether, after adjusting for age and race and ethnicity, the same higher usage of CH modalities among women compared to men that was observed in the full population was seen in the subgroups of adults with different chronic health conditions. We found no statistically significant sex difference in use of vegetarian/vegan diet among adults with diabetes, hypertension, and/or heart disease, but the overall prevalence of use of vegetarian/vegan diet was relatively low in all of these subgroups. Women remained more likely than men to have used MBSM techniques, prayer/spiritual practice, and MBSM/PSP among adults with diabetes, hypertension, and/or heart disease, and more likely to have used prayer/spiritual practice among adults with fair/poor sleep quality and chronic stress. Women were also more likely than men with hypertension, heart disease, fair/poor sleep quality, and chronic stress to have used massage therapy, and were more likely than men with hypertension and fair/poor quality sleep to practice yoga/Pilates.

Comparing Complementary Health Modality use in 2014/2015 to 2020

We found statistically significant increases between 2014/2015 and 2020 in use of vegetarian or vegan diets (middle-aged men and women, P < 0.001), MBSM techniques (men and women in both age groups), prayer (middle-aged men and older-aged men and women), and yoga/Pilates (men and women in both age groups) (Figure 1). No significant difference was seen for massage. Use of ≥1 CH modality was significantly higher in 2020 for all age-sex groups: increasing from 57.8% (CI 56.2%–59.4%) to 64.8% (CI: 62.3-67.4) among middle-aged women, 37.2% (CI: 35.3%–39.1%) to 45.1% (CI: 42.2%–48.0%) among middle-aged men, 46.0% (CI: 43.7%–48.2%) to 53.9% (CI: 51.6%–56.2%) among older-aged women, and 28.1% (CI: 26.0%–30.2%) to 34.2% (CI: 31.9%–36.6%) among older-aged men.

Figure 1.

Comparison of complementary health modality use, 2014/15 vs 2020.

Discussion

In this study, we examined prevalence of use of five CH modalities (vegetarian/vegan diet, MBSM techniques, prayer/spiritual practice, MBSM and/or prayer/spiritual practice, yoga/Pilates, and massage therapy) and use of ≥1 of these modalities by middle-aged and older-aged adults in a community-dwelling Northern California health plan population, how usage varied by patient demographic characteristics and among adults with different chronic conditions, and how usage changed between 2014/2015 and 2020. In the overall study population, approximately half of adults had used ≥1 of these five CH modalities, with MBSM techniques and prayer/spiritual practice being the most widely used and vegetarian/vegan diet the least widely practiced. Additionally, for all modalities studied except for massage therapy, we observed significant increases in use from 2014/15 to 2020. However, in 2020, only one-fourth of adults overall were using MBSM and prayer/spiritual practice modalities, about 17% using yoga/Pilates and massage therapy, and under 10% using vegetarian/vegan diets. Women were more likely than men to be using each of the five CH modalities, and within both sexes, middle-aged adults were more likely than older-aged adults to use each of the CH modalities except prayer/spiritual practice. Our findings of greater CH use among women and younger adults is consistent with prior research.^26,27

Our study is among the first contemporary studies to estimate the use of CH modalities across different chronic health conditions. Notably, we found that well under 10% of patients with diabetes, hypertension, or heart disease were following a vegetarian diet, which has been repeatedly shown to improve outcomes in these conditions.¹⁷ In addition, MBSM techniques were used by about 20% of adults with cardiovascular conditions, about one-fourth of adults with fair or poor sleep quality, and less than half (40%) of adults reporting chronic high levels of stress and tension. Approximately one-fourth of adults across all five conditions did use prayer or spiritual practices to help manage or prevent health problems, with more than one-third of adults with cardiovascular conditions or sleep issues and over half of adults with chronic stress using either MBSM, prayer, or spiritual practices. While we did not have sufficiently sized subgroups to explore racial/ethnic differences in use of MBSM techniques and prayer within these chronic conditions, we assume, based on findings from the full study population, that Black and Latino adults with these chronic conditions are less likely to be using MBSM techniques and more likely to be using prayer. Since both prayer and MBSM have similar positive effects on health, a culturally sensitive approach would be to encourage regular use of either modality, as well as potentially suggesting that some elements of MBSM, such as mindful breathing, could be beneficially incorporated into or between meditation or prayer sessions.

Overall, we found relatively low use of the five CH modalities we studied by adults with chronic health conditions that could potentially be better managed with their use. These findings may be highly relevant for primary care practice. Indeed, four of the CH modalities (MBSM techniques, prayer/spiritual practice, yoga/Pilates, and vegetarian or predominantly plant-based diet) can be learned through in-person or virtual training, and once learned, are quite inexpensive for patients to implement and sustain, unless they decide to join a fee-for-class group. Healthcare providers, especially those interested in the Lifestyle Medicine first approach that considers Lifestyle Medicine as the foundation for a whole person approach to all healthcare, can play an important role in recommending these CH modalities to their patients. However, they must first become more knowledgeable about how these modalities can help certain conditions and understand where to refer patients who express interest in learning how to use them. Further, while most commercial and government-funded health insurers do not offer coverage for massage therapy or yoga classes as a benefit, patients may be able to get at least partial reimbursement for out-of-pocket costs for these CH modalities from their healthcare reimbursement, healthcare savings, or flexible spending accounts with a form completed by a licensed healthcare provider that recommends a specific CH modality for treatment of a diagnosed health condition.³⁰

Strengths of our study include the large sociodemographically diverse study population, measurement of multiple CH modalities, and use of comparison data within the same health plan to examine how CH modality use changed from 2014/2015 to 2020. However, we acknowledge some limitations that may affect generalizability of the study results. First, we reported on an aggregated Asian/PI group, which may mask Asian ethnic subgroup differences in CH use. Second, while we were able to estimate use of the five CH modalities among adults with different types of chronic conditions, we were unable to link use of the CH modalities specifically to management of those conditions. Third, the survey was administered only in English, so racial/ethnic differences identified in our analyses are not generalizable to adults who do not read and understand English well. Fourth, post-stratification weighting of the respondent sample to reflect the underlying age, sex, and racial/ethnic composition of the health plan population may not have overcome all sources of survey nonresponse bias. Finally, our study sample was drawn from members of a very large but single integrated healthcare delivery system located in a geographic region where previous national surveys have shown a higher prevalence of CH use compared to other parts of the U.S.²⁶

Conclusion

The percentages of adults who use complementary health modalities has been increasing, suggesting that many patients may be open to an integrative and Lifestyle Medicine approach to their health care. This positive trend should encourage physicians, especially those in primary care or Lifestyle Medicine clinics, to incorporate relevant evidence-based CH modalities into their practice. The National Center for Complementary and Integrative Health urges a greater focus on implementation science to study how evidence-based CH modalities can be best integrated into clinical settings to improve patient outcomes.³¹ Future research is needed to better understand and develop ways to overcome potential barriers to integration of CH into clinical practice, such as reimbursement considerations, provider familiarity with available resources, and patient expectations (i.e., expecting to get prescription medication rather than a referral for CH).

Footnotes

Acknowledgments

The authors would also like to thank the survey team and all the survey participants for participating in the Member Health Survey.

Author Contributions

CQ, NG, and JL conceived and designed the study; NG acquired the data and conducted the data analyses; CQ, NG, and JL contributed to the interpretation of the data; CQ, NG, JL and NR drafted the manuscript; all authors approved the final version for publication.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Nancy Gordon received support from the Kaiser Permanente Northern California Community Health Program.

Ethical Statement

ORCID iDs

Cindy W. Qian

Nancy P. Gordon

Data Availability Statement

The Kaiser Permanente Northern California (KPNC) Institutional Review Board has not provided approval for Member Health Survey data to be placed in a public access repository. However, researchers can request access to use this study data by contacting the corresponding author (NPG).

Appendix

References

National Center for

Complementary and Integrative Health. Complementary, alternative, or integrative health: what’s in a name? NCCIH; 2021. https://www.nccih.nih.gov/health/complementary-alternative-or-integrative-health-whats-in-a-name. Accessed 7 June 2024.

Rippe

. Lifestyle medicine: the health promoting power of daily habits and practices. Am J Lifestyle Med. 2018;12(6):499-512. doi:10.1177/1559827618785554.

Stussman

Nahin

Barnes

Ward

. U.S. physician recommendations to their patients about the use of complementary health approaches. J Alternative Compl Med. 2020;26(1):25-33. doi:10.1089/ACM.2019.0303.

Janssen

Heerkens

Kuijer

Van Der Heijden

Engels

. Effects of mindfulness-based stress reduction on employees’ mental health: a systematic review. PLoS One. 2018;13(1):e0191332. doi:10.1371/JOURNAL.PONE.0191332.

Darehzereshki

Dehghani

Enjezab

. Mindfulness-based stress reduction group training improves of sleep quality in postmenopausal women. BMC Psychiatr. 2022;22(1):210-254. doi:10.1186/S12888-022-03869-4/TABLES/5.

Wang

Szabo

. Effects of yoga on stress among healthy adults: a systematic review. Alternative Ther Health Med. 2020;26(4):58-64.

Chen

Shen

, et al. Effect of Pilates on Sleep Quality: a systematic review and meta-analysis of randomized controlled trials. Front Neurol. 2020;11:158. doi:10.3389/FNEUR.2020.00158.

Panjwani

Dudani

Wadhwa

. Sleep, cognition, and yoga. Int J Yoga. 2021;14(2):100-108. doi:10.4103/IJOY.IJOY_110_20.

Baek

Lee

Gil

Jung

H-W

Jang

I-Y

. Clinical effects of using a massage chair on stress measures in adults: a pilot randomized controlled trial. Compl Ther Med. 2022;66:102825. doi:10.1016/j.ctim.2022.102825.

10.

Samuel

Gururaj

Kumar

Vira

Saxena

PUP

Keogh

JWL

. Randomized control trial evidence for the benefits of massage and relaxation therapy on sleep in cancer survivors—a systematic review. J Cancer Surviv. 2021;15(5):799-810. doi:10.1007/S11764-020-00972-X/TABLES/2.

11.

Belding

Howard

McGuire

Schwartz

Wilson

. Social buffering by God: prayer and measures of stress. J Relig Health. 2010;49(2):179-187. doi:10.1007/S10943-009-9256-8/METRICS

12.

Çoruh

Ayele

Pugh

Mulligan

. Does religious activity improve health outcomes? A critical review of the recent literature. Explore. 2005;1(3):186-191. doi:10.1016/J.EXPLORE.2005.02.001.

13.

Seeman

Dubin

Seeman

. Religiosity/spirituality and health. A critical review of the evidence for biological pathways. Am Psychol. 2003;58(1):53-63. doi:10.1037/0003-066X.58.1.53.

14.

Hastings

. Not a lonely crowd? Social connectedness, religious service attendance, and the spiritual but not religious. Soc Sci Res. 2016;57:63-79. doi:10.1016/J.SSRESEARCH.2016.01.006.

15.

Koenig

. Research on religion, spirituality, and mental health: a review. Can J Psychiatr. 2009;54(5):283-291. doi:10.1177/070674370905400502.

16.

Dinu

Abbate

Gensini

Casini

Sofi

. Vegetarian, vegan diets and multiple health outcomes: a systematic review with meta-analysis of observational studies. Crit Rev Food Sci Nutr. 2017;57(17):3640-3649. doi:10.1080/10408398.2016.1138447.

17.

Remde

Deturk

Almardini

Steiner

Wojda

. Plant-predominant eating patterns – how effective are they for treating obesity and related cardiometabolic health outcomes? – a systematic review. Nutr Rev. 2022;80(5):1094-1104. doi:10.1093/NUTRIT/NUAB060.

18.

Neuenschwander

Stadelmaier

Eble

, et al. Substitution of animal-based with plant-based foods on cardiometabolic health and all-cause mortality: a systematic review and meta-analysis of prospective studies. BMC Med. 2023;21(1):404. doi:10.1186/S12916-023-03093-1.

19.

Conversano

Orrù

Pozza

, et al. Is mindfulness-based stress reduction effective for people with hypertension? A systematic review and meta-analysis of 30 years of evidence. Int J Environ Res Publ Health. 2021;18(6):2882. doi:10.3390/IJERPH18062882.

20.

Tyagi

Cohen

. Yoga and hypertension: a systematic review. Alternative Ther Health Med. 2014;20(2):32-59.

21.

Jayawardena

Ranasinghe

Chathuranga

Atapattu

Misra

. The benefits of yoga practice compared to physical exercise in the management of type 2 Diabetes Mellitus: a systematic review and meta-analysis. Diabetes Metabol Syndr. 2018;12(5):795-805. doi:10.1016/j.dsx.2018.04.008.

22.

Sousa

VGS

Pertinni de Morais

Maria Souza

, et al. The effect of Pilates on metabolic control and oxidative stress of diabetics type 2 - a randomized controlled clinical trial. J Bodyw Mov Ther. 2021;27:60-66. doi:10.1016/j.jbmt.2021.01.004.

23.

Khatri

Mathur

Gahlot

Jain

Agrawal

. Effects of yoga and meditation on clinical and biochemical parameters of metabolic syndrome. Diabetes Res Clin Pract. 2007;78(3):9-10. doi:10.1016/j.diabres.2007.05.002.

24.

Xiong

Zhang

. Massage therapy for essential hypertension: a systematic review. J Hum Hypertens. 2014;29(3):143-151. doi:10.1038/JHH.2014.52.

25.

Kessler

Davis

Foster

, et al. Long-term trends in the use of complementary and alternative medical therapies in the United States. Ann Intern Med. 2001;135(4):262-268. doi:10.7326/0003-4819-135-4-200108210-00011.

26.

Goldstein

Brown

Ballard-Barbash

, et al. The use of complementary and alternative medicine among California adults with and without cancer. Evid Based Complement Alternat Med. 2005;2(4):557-565. doi:10.1093/ECAM/NEH138.

27.

Clarke

Black

Stussman

Barnes

Nahin

. Trends in the use of complementary health approaches among adults: United States, 2002-2012. Natl Health Stat Report. 2015;79:1-16. https://www.cdc.gov/nchs/data/nhsr/nhsr079.pdf. Accessed 7 June 2024.

28.

Gordon

NP.

Similarity of adult Kaiser Permanente members to the adult population in Kaiser Permanente’s Northern California service area: comparisons based on the 2017/2018 cycle of the California Health. Interview Survey 2020.

29.

Gordon

Lin

. The Kaiser Permanente Northern California adult Member Health Survey. Perm J. 2016;20(4):15-225. doi:10.7812/TPP/15-225

30.

Cigna HealthCare.

Which expenses are eligible for HSA, FRA, and HRA reimbursement . https://www.cigna.com/individuals-families/member-guide/eligible-expenses. Accessed 13 August 2024.

31.

Clark

Edwards

Murray

Langevin

. Implementation science methodologies for complementary and integrative health research. J Alternative Compl Med. 2021;27(Suppl 1):S7-S13. doi:10.1089/ACM.2020.0446.