Nutrition

Rachel Balick

All pharmacists know that for many conditions, medication isn’t enough. True management of chronic diseases takes a 360° approach that includes exercise, smoking cessation, and—unavoidably—nutrition. As trusted and accessible providers, pharmacists can help their patients make healthy food choices and changes. But how?

Keep it simple

Kristi L. King, MPH, RDN, CNSC, LD, senior pediatric dietitian at Texas Children’s Hospital in Houston and a clinical instructor at Baylor College of Medicine, says pharmacists shouldn’t be afraid to ask patients about their diet.

“Ask if they eat breakfast, consume alcohol, consume dairy products, eat fruits and vegetables, or eat out frequently,” she said.

Education about nutrition can help patients reduce their reliance on medications and supplements and aid in deprescribing. King advises pharmacists to keep it simple.

Patients may be exposed to misinformation and bad advice. Despite what they see in magazines, online, or on social media, patients need to know that their bodies require all macronutrients to function properly. “That includes carbohydrates,” King said.

Hydration is a good place to start. “Patients should drink plenty of water—minimum 16 oz in the morning, 16 oz at lunch, 16 oz at dinner, and 16 oz before bed,” she said.

It’s okay to add fresh fruit to water to change its flavor, and carbonated water counts, too. Adequate hydration can improve mood and sleepiness—and help kick the caffeine habit. It can also help with weight loss and maintenance, as it can curtail overeating.

Other tips

Here’s another simple piece of advice: Fill half your plate at lunch and dinner with fruits and vegetables. If patients aren’t already eating fruits and veggies, they can try adding one to breakfast, then one to lunch, then one to dinner as well. That way they can work up to the “half the plate” goal.

“Fruits and vegetables provide more than just vitamins and minerals,” King said. They also provide fiber. “Fiber is one of the biggest deficiencies in our diets as Americans,” she said, and fiber from the fruits and vegetables “will help to keep you full, lower your heart disease risk, as well as help keep the colon moving and healthy.”

Deficiencies in vitamin D are also prevalent in the United States “Consuming three servings per day of low-fat dairy or calcium and vitamin D–enriched foods will meet your requirements,” King said.

Patients who eat out frequently can make manageable changes. “If it’s fast food that fuels you, try replacing the french fries with a side salad,” King said. “Want the french fries? Get a grilled chicken breast instead of fried, and then enjoy the fries.”

Pharmacists should tell patients about possible food–drug interactions and how to manage them. For example, green leafy vegetables and other foods that contain vitamin K can have an effect on efficacy of warfarin therapy. Grapefruit and grapefruit juice can affect the concentration of CYP3A4 inhibitors, such as statins and some calcium channel blockers. Calcium binds to certain antibiotics and can make them ineffective. Using alcohol and acetaminophen can be dangerous because both are metabolized by the liver.

“Patients eating healthful foods are usually fine, as long as the intake is consistent so that internal normalized ratio monitoring takes this into account,” said Kim Croley, PharmD, clinical pharmacist at Laurel Senior Living in London, KY.

Start slowly to go far

“Small steps equal big changes, so [dietitians] help patients identify one or two things they feel they can change but that will have a big impact,” said Kristen F. Gradney, MHA, RDN, LDN, senior director of health centers in schools at Our Lady of the Lake Children’s Hospital in Baton Rouge, LA.

It’s best to let the patient drive those decisions, she said. “Ask patients what they eat and what they are interested in changing. Then offer resources and guides to help in those areas. Again, let the patient drive the decision making and goal setting.”

One manageable change is switching from regular soda to diet soda for a month, with the ultimate goal of switching entirely to water.

“This would have a huge impact on diabetes without changing anything else. The patient will see improvements and be motivated to incorporate another strategy,” Gradney said.

Gradney urges pharmacists to encourage the basics: more fruits, vegetables, whole grains, and water; and reduced intake of sugar, salt, and high-fat foods (e.g., anything fried). Highlight the foods that have the greatest impact on their disease state.

“Simple carbohydrates and sugar affect diabetes the most. Saturated fat and cholesterol will affect heart disease. Sodium and salt affect hypertension. Potassium, protein, phosphorus, and sodium affect chronic kidney disease patients,” she said.

But consider that not everyone has access to nutritious food or the luxury to adhere closely to nutrition advice.

“Some of your patients will live in food deserts, have little income and limited food choices, or may not be able to cook or obtain healthier foods,” Gradney said.

She tells pharmacists to be aware of what resources—such as food banks, traveling farmers’ markets, and community feeding sites—are available in their area and to tell patients about them.

Nutrition throughout the lifecycle

Nutrition requirements change over our lifespan. “Obviously, you require the most kcal/kg when you are an infant, child, and adolescent,” King said. “As we age, our overall kcal needs decrease due to lack of activity and loss of muscle mass.”

Macronutrient requirements also change. Children ages 1 through 3 require 30% to 40% of total kcal from fat, 5% to 20% from protein, and 45% to 65% from carbohydrates. From 4 to 18 years, kids should get 25% to 35% of total kcal from fat, 10% to 30% from protein, and 45% to 65% from carbohydrates.

People ages 18 or older require 20% to 35% total kcal from fat, 10% to 35% from protein, and 45% to 65% from carbs.

Micronutrients like calcium (women need more), vitamin D (men and women get different benefits), fiber (men need more), and B vitamins (men need more) tend to be more age- and gender-specific, King said.

“Supplements are not a cure-all and are not a substitute for a well-balanced diet,” said Gradney.

But sometimes it’s hard for caregivers to hear that supplements are no longer the best choice for older adults, who may take dozens of prescriptions.

“It’s not that they disagree with medicine changing—it’s the emotion of ‘My mom is changing,’ or ‘My dad is changing,’” said Croley. “‘My mom has always taken that vitamin. I just don’t know how she would act if we took it away.’”

Croley makes sure patients and caregivers know that she works with a staff dietitian to ensure that patients aren’t sacrificing nutrition. “We will make certain that the foods they receive will include these vitamins, so they won’t have to take an extra supplement.”

The staff at Croley’s facility take nutrition seriously. “Our dietitian doesn’t buy all these therapeutic diets, but instead gives people healthful, flavorful food,” she said. “Eating is a basic function of a human being, and so we try to make it as enjoyable as we can.”

Your advice matters

“Patients truly value your recommendations and advice, so refrain from offering advice based on fad diets or trends,” Gradney said. “Patients often get confused because trends come and go, usually without long-lasting outcomes.”

King concurs. “There is no one ‘nutrition prescription’ that works for everyone. What works for you may not work for your patients or your patient’s sister’s aunt’s neighbor.”

Pharmacists should rely on science. “As a pharmacist, it is important to use evidence-based practices [like you would for medications], even when talking about nutrition.”

Living a healthy lifestyle takes practice, she added. “It is important that you continue to encourage your patients to make changes and stick with it,” she said. “This is a marathon, not a sprint.”

Reach out to a local dietitian if necessary. “They are usually willing to guide you and provide resources on topics that may help all patients,” Gradney said.

King suggests having a local registered dietitian nutritionist come speak to staff. “It might be beneficial, as each patient population the pharmacists might be dealing with is different, and a local RDN may best know what to home in on.”

Gradney emphasizes that medication is not a replacement for eating well and being physically active. “They work together,” she said.

Still, lifestyle changes can’t always replace medication, even if patients follow all nutrition and activity recommendations.

“Instead of the quote ‘Let food be thy medicine,” I like to say, ‘Let food be part of thy medicine,’ ” King said.