patients with ibd may have disabling symptoms such as frequent diarrhea , often with blood or mucus discharge , abdominal pain , weight loss , malabsorption , malnutrition , and fatigue 1 .
moreover , patients may be affected by extraintestinal manifestations involving other organs such as the joints , eyes , skin , liver , and bile ducts 2 .
the cause of ibd is unknown and there is no medical cure , although several therapeutic advances have been made in recent years ; medical and surgical treatment for ibd is complex .
current treatment paradigms recommend the use of immunomodulators with or without biological therapy aiming at maintaining clinical and endoscopic remission to reduce the inflammatory burden , minimize complications , and the need for surgery , and as a result achieve an improved quality of life for the patient 3,4 .
there is an increasing interest in and use of complementary and alternative medicine ( cam ) in patients with chronic diseases , including those with ibd 58 .
patients with ibd may turn to cam for various reasons : for example , when conventional therapies are inadequate 9 or associated with adverse side effects , or for symptomatic relief and to regain control over their disease 10 .
the amount of steroid medication may be a predictor of cam use 11 ; moreover , cam use may indicate psychosocial distress in patients with ibd 12,13 .
the terms complementary medicine and alternative medicine refer to a broad set of healthcare practices that are not part of a country s own tradition and are not fully integrated into the dominant healthcare system .
tm has a long history and is the sum of the knowledge , skills , and practices on the basis of the theories , beliefs , and experiences indigenous to different cultures , whether explicable or not in the maintenance of health 14 .
there are different types of cam : whole medical systems ( homeopathic medicine , traditional chinese medicine , ayurveda ) , mind  body medicine ( meditation , prayer , healing ) , natural products ( herbs , also known as botanicals , vitamins and minerals , and probiotics , often sold as dietary supplements ) , manipulative and body - based practices ( chiropractic or osteopathic manipulation , massage ) , and energy medicine ( qi gong , reiki , therapeutic touch , the use of magnetic fields ) 1517 .
overall , 30% of the world s population do not have access to conventional medicine and for these patients , herbal medicines and tm are the main options 14 .
a review of the who in 142 countries showed that , in 99 countries , cam , that is , natural products ( herbal products and dietary supplements ) are sold over the counter without prescriptions 17 .
cam is mostly used for self - care 18 , and is often recommended by friends .
many cam treatments are available in our present - day society and the quality of the information on cam , often provided by the media and the internet , is variable . in general , a wide range of cams are recommended for many conditions , and a variety of treatments are recommended for the same conditions .
today , some cam treatments are supported by evidence from randomized - controlled trials , meta - analyses , and systematic reviews 1922 , and there are several interesting studies on cam for the treatment of ibd 19 .
a recent review of clinical trials of various herbal therapies for ibd 23 presents the most important studies on aloe vera gel 24 , polyphenols ( green tea ) 2527 , wheat grass juice 28 , bilberry 29 , wormwood 30,31 , boswellia serrata 
 19,32 , cannabis 33 , and chinese herbal medicine 34 .
probiotics have been shown to increase the clinical response and remission rate in mild to moderate uc 37,38 and to prevent pouchitis 39 .
considering the mounting evidence that dietary changes influence gut microbiome , dietary intervention studies have been attempted 40 , and as patients are becoming more interested in and are using specific diets to better control the disease 41 , diets might be considered cam .
studies using psychological interventions comprising relaxation techniques , patient education 44 , and psychotherapy , however , showed that psychotherapy had no effect on disease activity , health - related quality of life , or emotional status 45 .
however , a recently published study showed improved anxiety , quality of life , and mindfulness after a stress - reduction program on the basis of mindfulness in patients with cd 46 .
there are safety aspects because some herbal - based cams may be associated with adverse side effects and may cause interactions with conventional therapy 48,49 .
it is noteworthy that there is emerging evidence that cam therapies may modulate or disrupt the immune system 32 .
thus , the use of cam in patients with ibd needs to be considered in daily practice when making clinical decisions .
this multicenter survey was conducted to determine the extent of cam use , the reason for cam use , and perceived positive or negative effects from cam in patients with ibd in sweden .
eight hundred and fifty - four patients with ibd from 12 swedish hospitals were invited to participate in the study . a control group matched for age and sex , urban or rural , and geographic area was recruited .
ten of the ibd centers were university based ; one was a large teaching hospital , one was a private clinic , and one was a nonprofit hospital .
the inclusion criterion was an established diagnosis of ibd according to medical records being treated at the clinic .
the patients were contacted at the ibd centers by an ibd nurse or a physician who provided oral and written information on the study . if the patients were willing to participate , they filled in a questionnaire either at the clinic or at home using a prestamped , addressed reply envelope .
all data sampling was performed at each ibd center between august 2008 and june 2009 .
the individuals in the control group were selected randomly from a residence registry , statens personadressregister ( spar ) .
spar includes all individuals who are registered as residents in sweden and the data are updated continuously from the swedish population register .
an age , sex , and residence match was performed after the first 300 patients with ibd had been included .
the questionnaire was sent by post to 1400 individuals together with an informative letter explaining the study , and a stamped , addressed reply envelope .
the questionnaire was developed from a previously used questionnaire from an international survey , in which two of the authors ( l.o .
after updating the previous questionnaire with the help of an expert group on integrative care and cam 50 , a final list of 24 different cams was extracted .
the respondents were asked to indicate the type and frequency of cam use ( use in the past year , use in the last 2 weeks ) , perceived positive and negative effects of cam , and their source of cam information .
others if the particular cam used was not listed . further data on demographic characteristics such as age , sex , education , marital status , employment status , urban versus rural residence , annual income , diet , and lifestyle habits ( tobacco and alcohol use ) were collected .
the questionnaire also included questions on disease characteristics , type of ibd , current symptoms , year of diagnosis , conventional medication use , and perceived adverse events from conventional medication .
for comparison between two groups , fisher s exact test was used for dichotomous variables , the mantel 
odds ratio and confidence interval ( ci ) ( adjusted for age , sex , residence , and diet ) were calculated for the association of cam use between ibd patients and controls .
all participators were informed that participation was voluntarily and that they could withdraw at any time without consequences .
the study was approved by the ethical committee for all participating sites ( dnr 2008/4:6 , 2009/85232 ) .
eight hundred and fifty - four patients with ibd from 12 swedish hospitals were invited to participate in the study . a control group matched for age and sex , urban or rural , and geographic area was recruited .
ten of the ibd centers were university based ; one was a large teaching hospital , one was a private clinic , and one was a nonprofit hospital .
the inclusion criterion was an established diagnosis of ibd according to medical records being treated at the clinic .
the patients were contacted at the ibd centers by an ibd nurse or a physician who provided oral and written information on the study . if the patients were willing to participate , they filled in a questionnaire either at the clinic or at home using a prestamped , addressed reply envelope .
all data sampling was performed at each ibd center between august 2008 and june 2009 .
the individuals in the control group were selected randomly from a residence registry , statens personadressregister ( spar ) .
spar includes all individuals who are registered as residents in sweden and the data are updated continuously from the swedish population register .
an age , sex , and residence match was performed after the first 300 patients with ibd had been included .
the questionnaire was sent by post to 1400 individuals together with an informative letter explaining the study , and a stamped , addressed reply envelope .
the questionnaire was developed from a previously used questionnaire from an international survey , in which two of the authors ( l.o .
after updating the previous questionnaire with the help of an expert group on integrative care and cam 50 , a final list of 24 different cams was extracted .
the respondents were asked to indicate the type and frequency of cam use ( use in the past year , use in the last 2 weeks ) , perceived positive and negative effects of cam , and their source of cam information .
others if the particular cam used was not listed . further data on demographic characteristics such as age , sex , education , marital status , employment status , urban versus rural residence , annual income , diet , and lifestyle habits ( tobacco and alcohol use ) were collected .
the questionnaire also included questions on disease characteristics , type of ibd , current symptoms , year of diagnosis , conventional medication use , and perceived adverse events from conventional medication .
the inclusion criterion was an established diagnosis of ibd according to medical records being treated at the clinic .
the patients were contacted at the ibd centers by an ibd nurse or a physician who provided oral and written information on the study . if the patients were willing to participate , they filled in a questionnaire either at the clinic or at home using a prestamped , addressed reply envelope .
all data sampling was performed at each ibd center between august 2008 and june 2009 .
the individuals in the control group were selected randomly from a residence registry , statens personadressregister ( spar ) .
spar includes all individuals who are registered as residents in sweden and the data are updated continuously from the swedish population register .
an age , sex , and residence match was performed after the first 300 patients with ibd had been included .
the questionnaire was sent by post to 1400 individuals together with an informative letter explaining the study , and a stamped , addressed reply envelope .
the questionnaire was developed from a previously used questionnaire from an international survey , in which two of the authors ( l.o .
after updating the previous questionnaire with the help of an expert group on integrative care and cam 50 , a final list of 24 different cams was extracted .
the respondents were asked to indicate the type and frequency of cam use ( use in the past year , use in the last 2 weeks ) , perceived positive and negative effects of cam , and their source of cam information .
further data on demographic characteristics such as age , sex , education , marital status , employment status , urban versus rural residence , annual income , diet , and lifestyle habits ( tobacco and alcohol use ) were collected .
the questionnaire also included questions on disease characteristics , type of ibd , current symptoms , year of diagnosis , conventional medication use , and perceived adverse events from conventional medication .
for comparison between two groups , fisher s exact test was used for dichotomous variables , the mantel  haenszel -test was used for ordered categorical variables , and the mann 
odds ratio and confidence interval ( ci ) ( adjusted for age , sex , residence , and diet ) were calculated for the association of cam use between ibd patients and controls .
all participators were informed that participation was voluntarily and that they could withdraw at any time without consequences .
the study was approved by the ethical committee for all participating sites ( dnr 2008/4:6 , 2009/85232 ) .
of the 854 patients with ibd who were invited to participate , 164 did not return the questionnaires ( despite two reminders ) , 40 patients declined participation , and two were excluded owing to incomplete questionnaires . in total , 648 patients with ibd were included , yielding a response rate of 76% .
fourteen hundred individuals were invited to participate in the control group , of whom 440 responded , yielding a response rate of 32% .
twenty individuals declined participation , 33 letters were returned because of unknown address , one individual had died , and 906 did not return the questionnaires despite two reminders .
the patients with ibd who did not respond had a mean age of 41.6 years ; 48.5% were men , 39.2% had uc , and 42.9% had cd .
the nonresponders in the control group had a mean age of 40.8 years and 56.5% were men .
sociodemographic and disease data are listed in table 1 . of the 648 patients with ibd included in the study , 324 ( 50% ) had uc , 319 ( 49.2% ) had cd , and five ( 0.8% ) had ibdu .
the mean disease duration was 13.3 years and the mean age of the ibd patients with ibd was 42.7 years .
the individuals in the control group were significantly older than the patients with ibd ( mean age 45.9 years ; p=0.0004 ) . in the ibd group ,
48.3% of the patients were women and 58.1% of the controls were women ( p=0.002 ) .
significantly more of the controls were cohabiting compared with the patients with ibd ( p=0.04 ) .
patients with ibd lived significantly more often in urban areas ( p=0.001 ) compared with controls .
patients with ibd used various kinds of diets ( e.g. lacto vegetarian , lacto ovo vegetarian , vegan , and other types of diets ) more often than the controls who used more normal diets ( p<0.0001 ) .
sociodemographic and disease data , comparison between groups the level of education was similar in the patients and controls .
there were also no differences between patients with ibd and controls in occupation . in all , 28% of the patients with ibd were active tobacco users , 13.6% of them smoked and 14.8% used other tobacco ( e.g. snuff tobacco ) , the differences were not significant compared with controls .
current alcohol use was significantly higher among the controls than the patients with ibd ( p=0.005 ) .
overall , 93% of the patients with ibd reported the use of conventional medicine for ibd and 39.8% reported having experienced an adverse drug event from conventional medicine .
the controls often did not reply to the question on conventional medication or adverse events .
differences between patients with ibd and controls were adjusted for when comparing cam use between groups .
patients with ibd and individuals in the control group used different kinds of cam ( table 2 ) . of the patients with ibd ,
48.3% had used some kind of cam during the past year compared with 53.5% of the controls ( p=0.11 ) . however , after adjusting for age , sex , geographic residence , and diet in a multivariate analysis , a statistically significant difference was observed [ p=0.025 , odds ratio 1.16 ( 95% ci 1.021.32 ) ] .
the most frequently used cam among patients with ibd was massage , used by 21.3% , compared with 31.4% of the controls ( adjusted p=0.0003 ) .
the second most frequently used cam was herbal products , which were used by 18.7% of the patients with ibd compared with 22.3% of the controls ( adjusted p=0.018 ) .
the most commonly used natural products used by patients were omega 3 , probiotics , aloe vera , vitamins , arctic root , and other herbal products .
, kan yang , siberian ginseng , arctic root , and herbal products ( data not shown ) .
other cams used to a similar extent by patients with ibd and the controls were yoga , acupuncture , counseling , chiropractic , and meditation .
more controls used naprapathy than did ibd patients ( adjusted p=0.0055 ) , reflexology , and healing ( unadjusted p=0.026 ) .
type of complementary and alternative medicine used in patients with ibd within the last year , comparison between groups patients sought cam treatments to reduce pain , mainly pain from back , neck , joints , and bowel but also as strategies to handle their disease in order to decrease bowel symptoms and improve well - being .
ibd patients used cam primarily on their own initiative , but patients were also referred to cam practitioners or recommended cam use by healthcare professionals .
they obtained information on different cams mainly from friends and their next of kin , but also from the media , the internet , and the literature and from health food stores ( fig .
sources of information on cam ( % ) .  other comprised literature ( scientific articles , textbooks ) , own initiative , and wellness at workplace .
the perceived experiences of patients with ibd of cam are presented in table 3 . in all
, 83% of the patients with ibd who had used any cam during the past year perceived the cam as a positive experience , whereas 14.4% of them had experienced a negative effect ( or effects ) of the cam treatment .
the majority of the patients who used massage found it to be positive ( i.e. relaxing , providing pain relief , and well - being ) and 5.8% experienced negative effects ( pain , unease , or ill - being ) .
natural products were used by 18.7% of the patients with ibd ; 66.1% of these patients perceived positive effects , improved disease symptoms , well - being , and general improvement . there were no negative experiences of relaxation ; yoga was experienced as a means to achieve well - being , relaxation , and improved mobility .
patients with ibd who used acupuncture experienced pain relief , well - being , and improved disease symptoms . perceived effects of cam in patients with ibd ( n=648 )
the patients with ibd who did not respond had a mean age of 41.6 years ; 48.5% were men , 39.2% had uc , and 42.9% had cd .
the nonresponders in the control group had a mean age of 40.8 years and 56.5% were men .
sociodemographic and disease data are listed in table 1 . of the 648 patients with ibd included in the study , 324 ( 50% ) had uc , 319 ( 49.2% ) had cd , and five ( 0.8% ) had ibdu .
the mean disease duration was 13.3 years and the mean age of the ibd patients with ibd was 42.7 years .
the individuals in the control group were significantly older than the patients with ibd ( mean age 45.9 years ; p=0.0004 ) . in the ibd group , 48.3% of the patients were women and 58.1% of the controls were women ( p=0.002 ) .
significantly more of the controls were cohabiting compared with the patients with ibd ( p=0.04 ) .
patients with ibd lived significantly more often in urban areas ( p=0.001 ) compared with controls .
patients with ibd used various kinds of diets ( e.g. lacto vegetarian , lacto ovo vegetarian , vegan , and other types of diets ) more often than the controls who used more normal diets ( p<0.0001 ) .
sociodemographic and disease data , comparison between groups the level of education was similar in the patients and controls .
there were also no differences between patients with ibd and controls in occupation . in all , 28% of the patients with ibd were active tobacco users , 13.6% of them smoked and 14.8% used other tobacco ( e.g. snuff tobacco ) , the differences were not significant compared with controls .
current alcohol use was significantly higher among the controls than the patients with ibd ( p=0.005 ) .
overall , 93% of the patients with ibd reported the use of conventional medicine for ibd and 39.8% reported having experienced an adverse drug event from conventional medicine .
the controls often did not reply to the question on conventional medication or adverse events .
differences between patients with ibd and controls were adjusted for when comparing cam use between groups .
patients with ibd and individuals in the control group used different kinds of cam ( table 2 ) . of the patients with ibd ,
48.3% had used some kind of cam during the past year compared with 53.5% of the controls ( p=0.11 ) . however , after adjusting for age , sex , geographic residence , and diet in a multivariate analysis , a statistically significant difference was observed [ p=0.025 , odds ratio 1.16 ( 95% ci 1.021.32 ) ] .
the most frequently used cam among patients with ibd was massage , used by 21.3% , compared with 31.4% of the controls ( adjusted p=0.0003 ) .
the second most frequently used cam was herbal products , which were used by 18.7% of the patients with ibd compared with 22.3% of the controls ( adjusted p=0.018 ) .
the most commonly used natural products used by patients were omega 3 , probiotics , aloe vera , vitamins , arctic root , and other herbal products .
, kan yang , siberian ginseng , arctic root , and herbal products ( data not shown ) .
other cams used to a similar extent by patients with ibd and the controls were yoga , acupuncture , counseling , chiropractic , and meditation .
more controls used naprapathy than did ibd patients ( adjusted p=0.0055 ) , reflexology , and healing ( unadjusted p=0.026 ) .
type of complementary and alternative medicine used in patients with ibd within the last year , comparison between groups patients sought cam treatments to reduce pain , mainly pain from back , neck , joints , and bowel but also as strategies to handle their disease in order to decrease bowel symptoms and improve well - being .
ibd patients used cam primarily on their own initiative , but patients were also referred to cam practitioners or recommended cam use by healthcare professionals .
they obtained information on different cams mainly from friends and their next of kin , but also from the media , the internet , and the literature and from health food stores ( fig .
sources of information on cam ( % ) .  other comprised literature ( scientific articles , textbooks ) , own initiative , and wellness at workplace .
the perceived experiences of patients with ibd of cam are presented in table 3 . in all
, 83% of the patients with ibd who had used any cam during the past year perceived the cam as a positive experience , whereas 14.4% of them had experienced a negative effect ( or effects ) of the cam treatment .
the majority of the patients who used massage found it to be positive ( i.e. relaxing , providing pain relief , and well - being ) and 5.8% experienced negative effects ( pain , unease , or ill - being ) .
natural products were used by 18.7% of the patients with ibd ; 66.1% of these patients perceived positive effects , improved disease symptoms , well - being , and general improvement .
there were no negative experiences of relaxation ; yoga was experienced as a means to achieve well - being , relaxation , and improved mobility .
patients with ibd who used acupuncture experienced pain relief , well - being , and improved disease symptoms . perceived effects of cam in patients with ibd ( n=648 )
a high percentage of the patients with ibd ( 48.3% ) had used some kind of cam within the last year , which is in line with previous research ( 3268% ) in other western countries 5,8,10,5154 .
the most common cam use in the current study was massage , followed by natural products , relaxation , yoga , acupuncture , and counseling .
the use of cam was significantly higher in the control group ( 53.1 vs. 48.3% ) ; however , this high use of cam in the control group must be interpreted with caution because of the low response rate .
patients with ibd may be so used to conventional medication that they dare not use cam to a greater extent or they may be influenced by healthcare professionals showing a disparaging attitudes toward patients cam use 55 .
it has been argued that in the absence of critical assessment of cam , gastroenterologists could simply be supportive , cautious , and open - minded about widely available cams 6 .
overall , 93% of the patients with ibd in the present study reported the use of conventional medication and as many as 40% of these reported adverse event from conventional medicine .
this high figure of adverse drug events could be because of a selection bias because the patients responding to the questionnaires could be those explicitly interested in cam and/or those who had experienced adverse effects from conventional medicine .
however , patients on ibd medication often report adverse drug reactions , mainly from steroid therapy .
a review showed that adverse events lead to cessation of medication in up to 55% of patients being prescribed steroids , and 1011% of patients prescribed antitumor necrosis factor therapy and immunomodulators , 56 .
the ibd patients in our study sought cam treatments to reduce pain and to handle stress and symptom related to their disease .
the majority of the patients perceived positive effects from cam treatments , but interestingly , no major improvement in disease symptoms was observed . a significantly higher proportion of the controls ( 22.3% ) used natural products compared with patients with ibd ( 18.7% ) , controlled for age , sex , residence , and diet .
this was to some degree surprising because patients with a chronic disease were expected to use more cam compared with a control group .
this difference may possibly be explained by the fact that the controls were significantly older , more of them were women , more were living in urban areas / cities , and the controls were following more normal diets . with respect to patient safety ,
it is notable that as many as 18.7% of the patients with ibd in our study used natural products .
the patients also used other cams ( but to a lesser extent ) : anthroposophy ( 0.5% ) , ayurveda ( 0.3% ) , homeopathy ( 2.3% ) , and traditional chinese medicine ( 0.5% ) , which are not included in the 
the definition of cam used in this study in terms of natural products includes a variety of products , herbals ( botanicals ) , vitamins and minerals , and probiotics ( often sold as dietary supplements ) 16 .
research on the importance of vitamin d is increasing and clinicians may recommend ibd patients such products as vitamins , omega 3 , and probiotics 5759 ; however , the patients in the present study did identify these products as cams , indicating that they were not recommended these by their physicians .
a review showed that herbal therapy appeared to be effective in ibd , but the safety profile and long - term efficacy require further research 60 .
certain herbal therapies have been reported to have anti - inflammatory properties , and the use of these cams may theoretically cause interactions with conventional medicines .
herbal treatments may have toxic side effects , and some treatments are contraindicated and may be dangerous 49 .
liver toxicity has been described in the literature , for example , in relation to the consumption of noni juice 61,62 ; none of the ibd patients in the present study had used noni .
the results from the present study highlight the importance of healthcare professionals being aware of the potential effects , potential side effects , and interactions of such therapies and the fact that our patients are using these cams . a number of herbal - based and traditional medical products are registered and controlled by the swedish medical products agency 63 .
an european union directive incorporated into the who has a strategy that encourages countries to incorporate cams into conventional healthcare 14 .
legalization in sweden guides swedish healthcare professionals on how to relate to and recommend these herbal products .
this and the fact that patients with ibd do use these natural - based cams should be considered when making decisions in clinical care . however , there are some practical issues in sweden .
there is no general cam policy and cams have not been officially approved in healthcare or within the educational system ; thus , policy development is essential 64 .
we conclude that patients with ibd in sweden are using cam treatment to a large extent ( 48.3% ) , but the control group used cam to a greater extent ( 53.1% ) .
this should be interpreted with caution because of the low response rate in the control group .
patients with ibd might very well be influenced by healthcare professionals showing disapproving attitudes toward patients cam use 55 , thus hindering cam use .
the majority of the patients experienced positive effects from cams , mainly well - being , whereas no major improvement in disease symptoms was observed . in all , 40% of the patients had experienced adverse events from conventional medication , which may be a reason for cam use ; furthermore , the patients in this study experienced predominantly positive effects from cam therapies .
a high level of use of natural products was noted , more common in controls ( 22.3% ) compared with patients with ibd ( 18.7% ) , but still used by about one - fifth of the patients
. the possible risk of interaction with cam must be considered when prescribing conventional medication .
consequently , an open - minded dialog with our patients is necessary to determine their cam use .
 backgroundthere is an increasing interest in complementary and alternative medicine ( cam ) in patients with chronic diseases , including those with inflammatory bowel disease ( ibd ) . 
 patients may turn to cam when conventional therapies are inadequate or associated with side effects for symptomatic relief or to regain control over their disease . 
 the objectives were to explore cam use and perceived effects in ibd patients in comparison with a control group.methodsa cross - sectional , multicenter , controlled study was carried out . 
 ibd patients were invited from 12 ibd clinics in sweden . 
 controls were selected randomly from a residence registry . 
 a study - specific questionnaire was used for data collection.resultsoverall , 48.3% of patients with ibd had used some kind of cam during the past year compared with 53.5% in controls ( p=0.025 , adjusted for age , sex , geographic residence , and diet ) . 
 the most frequently used cam among ibd patients was massage ( 21.3% ) , versus controls ( 31.4% ) ( adjusted p=0.0003 ) . 
 the second most used cam was natural products , 18.7% in ibd patients versus 22.3% of the controls ( unadjusted p=0.018 ) . in all , 83.1% of the patients experienced positive effects from cam and 14.4% experienced negative effects.conclusionoverall , 48.3% of swedish ibd patients used some kind of cam and controls used cam significantly more . 
 natural products were used by one - fifth of the patients and even more by controls . 
 this is notable from a patient safety perspective considering the possible risks of interactions with conventional medication . in all 
 , 40% of the patients reported adverse events from conventional medicine . 
 patients experienced predominantly positive effects from cam , and so did controls . 