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Complementary and Alternative Medicine Use Among Hispanics in the

United States
Blanca I. Ortiz, PharmD; Kelly M. Shields, PharmD; Kevin A. Clauson, PharmD; Patrick G. Clay, PharmD

The Annals of Pharmacotherapy. 2007;41(6):994-1004.

Objective: To review the use of complementary and alternative medicine (CAM) in Hispanics in the US and highlight the
modalities most likely to be unfamiliar to healthcare practitioners.
Data Sources: A search of the literature published in English and a subsequent bibliographic search were conducted using
MEDLINE, International Pharmaceutical Abstracts, EMBASE, Cumulative Index of Nursing and Allied Health Literature,
and Manual Alternative and Natural Therapy Index System (1980-March 2007). Primary search terms included, but were not
limited to, Hispanic, Latino, complementary and alternative medicine, and dietary supplements. Studies that assessed or
evaluated the use of CAM in the Hispanic population were reviewed. Articles that included both Hispanics and non-
Hispanics were also included.
Study Selection and Data Extraction: The literature search yielded 42 articles focused on the use of CAM by Hispanics.
Survey was the most common method used in these studies, although some hybrid interviews were also conducted.
Data Synthesis: Hispanics were identified homogenously in some studies and more correctly as a heterogeneous population
in others. Some trials examined overall CAM use, whereas others looked at specific dietary supplements and herbs. Most
reports found a higher than expected rate of CAM use in Hispanics (50-90%). A number of products potentially unfamiliar to
healthcare practitioners, such as linden, sapodilla, and star anise, were reported as commonly used in several studies. Many
studies were limited by the sample size or use of only one Hispanic subgroup.
Conclusions: Hispanics use a wide range of CAM therapies, including several that may be unfamiliar to healthcare
practitioners. Understanding the rationale, motivations, and history of Hispanics' use of CAM will enhance the cultural
competence of healthcare professionals and help address these patients' medical needs.

In just 14 years, complementary and alternative medicine (CAM) use in the US increased from 33.8% to as high as 62%.[1-5]
Initially, CAM practices were defined as "medical interventions not taught widely at US medical schools or generally
available at US hospitals."[2] The National Center for Complementary and Alternative Medicine (NCCAM) definition is "a
group of diverse medical healthcare systems, practices and products that are not presently considered to be part of
conventional medicine."[4] With earlier studies focusing on identifying modalities such as herbal medicine, homeopathy, folk
remedies, megavitamins, energy healing, and massages, studies now include palliative and supportive care. Additionally,
ethnicity, education, age, and income have been identified as major predictors of CAM use.[1-3]

With CAM use rates reflecting influence by ethnicity, sex, and age, cultural competence presents an additional challenge to
healthcare professionals. Of all subpopulations, Hispanics are the fastest growing.[4-6] Consequently, it is of paramount
importance to improve comprehension of the rationale for and use of CAM within the Hispanic population.[4-6]

According to the US Census Bureau, the Hispanic population in 2002 accounted for 13.3% of the total population. Within
this population, responders reported their heritage or origin as approximately 66% Mexican, 14.5% Central and South
American, 9% Puerto Rican, 4% Cuban, and the remaining 6.5% from other Hispanic origins.[6] It is important to understand
that the term "Hispanics" encompasses a heterogeneous group. Although collectively contained in this grouping, each group
has differing dialects, foods, and traditions, as well as other factors predicated in part by country of origin. Consideration is
warranted for personal differences, socioeconomic status, migration status, subcultures, and life experiences, even when
countries of origin are similar. While it is difficult to make broad characterizations regarding CAM use, language, religion,
cultural values, and health beliefs are important commonalities shared among this population. Included as one important
commonality is the similarity of use of CAM.

A systematic literature search was conducted using MEDLINE, EMBASE, International Pharmaceutical Abstracts,
Cumulative Index of Nursing and Allied Health Literature, and Manual Alternative and Natural Therapy Index System.
Search terms included Hispanic, Latino, Latina, alternative medicine, complementary and alternative medicine, integrative
medicine, dietary supplements, folk medicine, folk remedies, herb, herbal product, medicinal plant, natural product, and
nutraceutical. The search was limited to English-only publications from 1980 to March 2007. Initial evaluation of citations to
determine inclusion was based on the title and abstract of the article. Studies that assessed or evaluated the use of CAM in
the Hispanic population were reviewed. Articles that assessed combinations of Hispanics and non-Hispanics were included.
A bibliographic search was also performed to identify articles that were not indexed in the targeted databases.

To better understand why a population demonstrates a vast diversity within itself, historical influences must be appreciated.
The unique health and healing philosophy shared by the Hispanic population is attributed to a fusion of cultures.[7-10] Ancient
native indigenes from Central and South America believed that natural forces in the sea, earth, and moon played an important
role in an individual's health. A healthy life could be achieved only by demonstrating respect for the power of these natural
forces. With the arrival of the Spanish conquistadors in the 16th century, the Catholic religion and Hippocrates' humoral
theory of health were introduced into the New World. According to this theory, health was dependent on the proper
distribution of the body's 4 humors: blood, phlegm, yellow bile, and black bile, which are classified based on their physical
properties as hot, cold, moist (wet), or dry.[7,8] Illness was attributed to an imbalance of these humors, and treatment was
targeted to restore balance.[7]

Religion and faith were also considered vital to the maintenance of health and well-being. Spiritual healing (curanderismo),
magic (santera), and some herbal remedies were introduced by African slaves, particularly in Brazil and the Caribbean.[7-11]
This blend of spiritual, humoral, and herbal health concepts was the base for the development of the hot/cold theory of health
and disease and the Hispanic CAM practices of today.

In the Hispanic theory of disease, ailments are thought to develop as a result of an imbalance between 2 humors: hot and
cold. Based on this principle, specific diseases and conditions are classified as hot (caliente) or cold (frio). Consequently, the
medications, remedies, and foods that are used to treat them are assigned descriptors accordingly. Therefore, the treatment
recommended for any condition will usually have the opposite classification or properties. For instance, cold diseases are
treated with hot remedies, while hot diseases are treated with cool or cold remedies ( ).[7,8]

Disease Classification Based on the Hot/Cold Theory[7-10]

Hispanic cultural values and traditions used in healing (categorized today as CAM) have been passed down through
generations. Concepts of sickness, health and healing, and religious faith are transmitted and learned as part of the rearing
process. For many Hispanics, CAM practices are both a part of their cultural roots and an integral part of their lives.[9,10] As
such, many Hispanics would agree that CAM does not meet the NCCAM established definition of "not presently part of
conventional medicine."[4] Healthcare professionals attempting to uncover CAM use in Hispanics must be cautious when
trying to elicit details about their nontraditional healing practices. It may also be useful to initiate a dialogue with the
influential female in the patient's life to obtain the most accurate and complete information.

Family, a predominant cultural factor among Hispanics, is considered a supportive and helpful network. Among traditional
Hispanic families, women are primarily responsible for maintaining the health and well-being of the family, while men
provide material support. To this end, providers must be cognizant that CAM knowledge (notably the use of herbs and home
remedies) is usually handed down from a female relative, such as mother to daughter (or from a grandmother or aunt).[9,10,12]
Usually, common illnesses are first managed outside of the formal healthcare system, and it is at the discretion of the
caregiver (often the mother) to decide when a disease is beyond her capacity to treat and requires "professional" help.[11,12]
This may not always immediately translate to an individual with an accredited healthcare license. Family friends or relatives
may serve as the next level of medical sources or caregivers.[9-12] As a healthcare provider makes inquiries into the history of
treatment for a diagnosis, several levels of care may need to be sifted through to obtain the full treatment history.

As Hispanics become acculturated within the US, they participate in a pluralistic healthcare network, including conventional
(Western) medicine and CAM. Some changes occur as new information is integrated. For instance, first-generation Hispanics
and new immigrants are more likely to hold traditional beliefs. This group may also be more likely to encounter access
problems related to language barriers or insurance coverage. Conversely, US-born Hispanics and their more educated
counterparts are more likely to have assimilated positive attitudes toward traditional medicine. Although a significant number
of Hispanics in the US use the conventional healthcare system, a substantial portion utilize at least one CAM modality either
alone or as part of conventional therapy.[13-53] CAM modalities are frequently used in support of chronic conditions such as
diabetes, hypertension, and asthma. An overview of 42 studies examining Hispanic use of CAM is shown in .[13-54]
 Complementary and Alternative Medicine Use Among Hispanics in the US
Some of the most commonly reported herbs used by Hispanic patients may be different from those most commonly used by
non-Hispanic patients ( ).[13-57] Surveys have reported common use of some products that may be unfamiliar to many non-
Hispanics including brook mint, linden, star anise, sapodilla, and passion flower.[40,47]
 Common Herbal Remedies Used by Hispanics in the USa

In the Hispanic hot/cold theory, diabetes mellitus is a hot disease.[7] Although the use of home remedies is always
encouraged, management of this condition relies primarily on conventional medical care. Home remedies for diabetes are
usually administered in combination with traditional medicine. Nopal (cactus), aloe vera juice, and bitter gourd are 3 of the
common home remedies used that may be unfamiliar to healthcare practitioners.[21,28,29,34] The efficacy of these therapies is yet
to be fully elucidated. Some published data suggest that nopal and bitter gourd may be helpful in reduction of blood glucose
levels. Nopal may exert its effect due to high fiber content or have some insulin-sensitizing properties, and components of
bitter gourd may have some insulin-like properties.[54-57]

Hypertension is also a hot illness according to the Hispanic hot/cold theory.[7] Anger (corajes), fear (susto), nervousness, and
thick blood are thought to be the most common causes of hypertension in this belief system. Cold remedies are used to treat
this condition including lemon juice, linden (tila) tea, passion flower tea (pasionara), and sapodilla (zapote blanco) tea.
[13,15,16,24]
Minimal information is available about the safety or efficacy of these products, but all should be treated as
pharmacologically active agents.

The use of CAM in the treatment of childhood illnesses such as asthma is a common practice among Hispanics. Hispanics
classify asthma as a cold disease; thus, remedies with hot qualities are used to restore this humoral imbalance. Home
remedies, such as traditional herbals and massages, account for the most popular modalities.[7] They are administered as
zumos or syrup mixtures. The most commonly used ingredients are whale oil, cod liver oil, honey/royal jelly, aloe vera juice,
oregano, onion/garlic, lemon, and castor and almond oil.[16-18,29,30,32,34] A commercial syrup known as Siete Jarabes is often
used by Puerto Ricans to treat cough, particularly in asthmatic patients.[12,16] Siete Jarabes is a honey syrup that contains a
mixture of sweet almond oil, castor oil, honey, wild cherry, licorice, and cocillana.

It is important for health professionals to demonstrate an open mind and acceptance of patients' interest and practices.[58] It
has been reported that Hispanics usually do not inform their physicians, pharmacists, or other healthcare providers about
their CAM practices. Moreover, if a negative attitude toward CAM use is perceived, they are even less likely to disclose this
information.

Lack of practitioner knowledge about patient CAM practices can put patients at increased risk of CAM-drug or CAM-disease
interactions. This lack of knowledge may also lead to unnecessary changes in therapy or diagnostic tests if a CAM-drug
interaction is leading to a change in therapeutic effect or to adverse effects. Since some CAM practices may not be beneficial
in certain disease states or may increase the risk of therapeutic failure, the use of these alternative treatment modalities
should always be ascertained. Additionally, healthcare providers should attempt to obtain a general knowledge regarding the
most common CAM practices of their patients.

Depending on a practitioner's style and setting, the following recommendations can be followed when assessing CAM use
during patient interviews.

1. Always deliver a message of tolerance and respect toward CAM use.

2. Assume an active role in discussing herbal remedies and other CAM modalities with patients.

3. Learn about herbs used for specific indications in certain populations through the use of continuing education
courses, textbooks, flash cards, or online databases (eg, Natural Medicine Comprehensive Database, Natural
Standard).

4. Inform patients about the lack of official standards of quality among dietary supplements, the possibility of drug
interactions, and the lack of information regarding the safety and efficacy of some CAM modalities.

5. Emphasize the importance of adherence to conventional therapy. Reliance on home remedies and certain CAM
modalities may lead to a high rate of nonadherence to prescribed regimens.

6. Whenever CAM use is not contraindicated, acknowledge incorporation of some common CAM remedies into a
patient regimen. This could help to improve adherence to conventional therapies and gain patients' trust. For instance,
when encouraging liquid intake for colds and flu, consider suggesting a natural tea drink or soup with other forms of
electrolyte replacement as part of the therapeutic regimen.

This collection of studies assessing CAM practices in Hispanics residing in the US reinforces the need for further
exploration. Critically needed are studies ascertaining the impact and validity of CAM modalities that influence healthcare
delivery among this population. While improving CAM awareness might help integrate some of these practices into the
conventional healthcare system, it is also likely to increase patients' trust and enhance adherence to conventional Western
medicine. Healthcare professionals must continually educate themselves regarding not only general, but also culturally
specific related CAM practices of their patients so that the most effective culturally sensitive care is provided. Understanding
culture and its impact on health attitudes and beliefs is a key to improving the assessment of CAM use among ethnic
minorities, including Hispanics.

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Reprint Address
Dr. Clauson, NSU Drug Information Center, 3970 RCA Blvd., Ste. 7006A, Palm Beach Gardens, FL 33410, fax 561/627-
0972, clauson@nova.edu

The Annals of Pharmacotherapy. 2007;41(6):994-1004. 2007 Harvey Whitney Books Company