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Clinical focus: your residents' daily diet and medicine may not always mix.

"Yes, nurse--tell my doctor I need a refill on ketoprofen, carbamezapine--and six oranges and apples, please."

Before you pick up the phone and seek psychiatric help for your resident, take note: a growing number of healthcare consumers now regard food as a form of medicine. The scientific focus on "functional foods" confirms what pharmacists and dietitians have long known: Diet and drugs can be closely related.

The functional-foods trend merely highlights how naturally occurring components of food can have pharmaceutical actions. Lycopene, for example, can play a role in preventing prostate cancer and omega-3 fatty acids help prevent heart disease. Thus, foods can contribute more to residents' state of health than just nutrients. In a long term care facility, the pharmacist and dietitian can team up to manage the complex and sometimes precarious relationship between food and medicine

Particular foods and nutritional supplements may alter drug absorption or interact with drug metabolism, making a drug more--or less--effective. They may alter timing of drug action. Or, they may interact with drugs to create dangerous health conditions.

On the other side of the coin, medicines can have nutritional side effects, interfering with nutritional care plans. One medicine may interfere with absorption or metabolism of a critical nutrient. Another medicine may create taste changes, appetite changes or gastrointestinal distress, affecting a resident's nutritional well-being and medical resilience.

What's behind it all?

Interactions can occur at many points. For starters, a dietary factor may influence the absorption of a drug. Once a drug is in the body, a dietary factor may influence its metabolism. It may compete with the drug or magnify the drug's action. Furthermore, a dietary factor may alter how a drug is eliminated from the body.

The severity of food-drug interactions varies from one combination to the next. One situation may create interest, without clinical significance. Another can have a profound impact, culminating in medical crisis. Some food-drug interaction management systems rate the risks and set priorities. To prevent clinical surprises, many healthcare teams develop monitoring and educational protocols to address key interactions.

To eat or not to eat

When a physician prescribes a drug with potent food interactions, the bottom-line advice in clinical care often distills into one of two categories: avoid a food (or nutrient) or include a food [see "Avoid a Food, page 18"]

It's worthwhile to note that for some of these interactions, it may be more important to gauge dosage according to diet, rather than avoid foods. The coffee-theophylline is a good example. If a patient is a heavy coffee drinker, some practitioners simply want to know this and moderate the dosage of theophylline. Here, it's simply important that the healthcare team identify the coffee-drinking habit. If the habit changes, the team needs to notice this, too.

Just how serious are some of these interactions? A patient overdosed on the theophylline-coffee combination may experience nervousness, tremor, and insomnia. The felodipine-grapefruit juice connection is one that can have a profound clinical impact, with a hypotensive crisis. Conversely, the MAO inhibitortyramine connection is one that can generate a hypertensive crisis.

In other dietary factors, alcohol can dissolve coatings on time-released drugs, leading to a quick, high dose followed by a drop in drug levels. An action as simple as breaking up a time-released pill to administer it with food can create the same type of problem.

Apart from food itself, use of vitamin and mineral supplements requires attention, too. For example, supplementation with vitamin E (400 IU or more per day) can lengthen clotting time, because Vitamin E itself is an anticoagulant. [See "Include a Food," page 18]

Among the elderly, blood concentrations of many vitamins may run low, according to nutrition research. One possible factor is ongoing drug therapies. Particular medications reduce availability of certain nutrients, or deplete body stores. For example, anti-convulsant medications reduce the body's supplies of vitamin D and folacin. To prevent deficiency, residents may need to drink more milk, eat folacin-rich foods, and/or take vitamin supplements. A drug as innocent as aspirin causes vitamin C loss. To prevent gastrointestinal bleeding, some practitioners advise eating vitamin C rich foods rather than taking oral supplements.

When a resident is following long-term pharmaceutical regimens, it's particularly important to monitor nutritional status. Gastrointestinal side effects, as well as taste changes or appetite changes, are extremely common side effects from medications.

Over time, a patient may lose weight and deplete lean body mass. In turn, a degree of malnutrition becomes a medical risk factor in surgery, immune response and tolerance of a broad range of therapies.

With the upsurge of complementary medicine in the US today, healthcare providers are focusing on the role of herbal supplements in the food drug arena. It's common for healthcare consumers (or well-meaning family members) to practice self-medication with herbs, apart from conventional medical care. By its very nature, complementary or alternative therapy is something a resident or concerned other may not report to the healthcare team [see "Herb Drug Interactions," page 14].

Management approaches

Clearly, managing the risk of food-drug interactions requires interdisciplinary communication and commitment. In a typical protocol, the pharmacist is responsible for contacting the physician when a potential for food-drug interactions arises. Counseling is required [see "Individualized Counseling," below). Dietary instructions pertaining to drug therapy become part of the diet order communicated to a food service department.

Some healthcare organizations rely on interdisciplinary care plans to gather rellevant pieces of the food-drug puzzle together. Computer software, Web sites and PDA (handheld computer) applications exist to provide ready reference [see "A Web Reference," below].

Precautions need to become part of the nursing chart. Nursing staff and other caregivers have ongoing contact with the resident and family, and are most likely to become aware of herbal supplements, gifts of food, or any other factor that may have a bearing.

Among team members, a pharmacist has extensive training in the actions and metabolism of medications, and keeps abreast of new therapies and related research. A dietitian or dietary manager has extensive training in the nutrient components of foods. Nursing staff have extensive interaction with residents and a strong trust relationship. By pooling their expertise, these team members can address the scientific aspect of therapeutic planning and then match food and nutrient lists to individual eating patterns and health habits to assure residents' well-being.


Counseling patients about food-drug interactions has long been a standard of JCAHO, and represents sound clinical management. How counseling responsibilities are assigned varies by institution--often involving a pharmacist, dietitian, and/or nurse--but they must be addressed in care protocols. A basic approach is to identify potential interactions proactively, trigger an education objective, and re-evaluate the list each time medication regimens change.

In addition, a thorough dietary history is essential to determine how a standard interaction list applies to the Individual resident. While reference charts may list several foods high in potassium, for example, most charts do not mention potatoes, tomatoes, broccoli, leafy greens and many other significant sources. The detail is too much to include in a standard "cheat sheet." A dietary history reveals the nutrient-dense food choices of an individual, as well as beverages of choice and other details that weave into customized diet planning. Residents and families also need specific advice about herbal and nutrition supplements, as well as herbal teas. Caregivers can advise residents and significant others to discuss any supplements with the team.

Many institutions use simple instruction sheets and drug information is a feature of many pharmaceutical management software packages. Food-drug interaction guidance is also available in searchable Web databases. Providing printed information in plain English and readable type is important reinforcement. However, a team member needs to sit down with a resident, explain dietary guidance, and apply it to the resident's dietary habits. In addition, it's critical to involve family and significant others, who could unknowingly undermine precautions when bringing in food items or feeding a resident off-site. Occupational and recreational therapists also need to be aware of dietary guidance, too. As follow-up to counseling, caregivers can exercise ongoing vigilance and offer periodic reminders.--S.G.

Herb-Drug Interactions

To find out whether herbal supplements may play a role in resident care, healthcare team members need to be alert and ask questions. Use of herbal supplements should be part of every dietary or medical history completed on admission. Here are some examples of herb-drug concerns.

Antidepressant Gingko--may increase Identify herbal
medications blood levels of the supplements and discuss
 medicine with physician

Antipsychotic Gingko--may cause Identify herbal
medications seizures supplements and discuss
 with physician

Coumadin/Warfarin Gingko; coenzyme Q-10; Identify herbal
 ginseng--all enhance supplements and discuss
 anticoagulant action; with physician
 could cause
 spontaneous bleeding

Insulin or oral Coenzyme Q-10, Identify herbal
hypoglycemic ginseng--can lower supplements and discuss
drugs blood sugar, with with physician
 potential for
 hypoglycemic crisis

Avoid a Food

Here are some examples of when a resident might need to avoid a food.


Coumadin/Warfarin Food high in vitamin K Limit foods high in
 (e.g. dark green leafy vitamin K while taking
 vegetables, broccoli, this drug
 liver) interfere with
 drug action

Digoxin Vitamin D Avoid vitamin D
 supplementation-- supplementation while
 enhances drug action; taking this drug
 can cause irregular

 Bran fiber or Avoid taking fiber with
 fiber-containing this medicine
 decrease drug

Felodipine Grapefruit juice (not Avoid grapefruit juice
(anti-hypertensive) orange juice)-- whithin a few hours
 increases before or after taking
 bioavailability and this drug
 can cause drop in
 blood pressure,
 flushing, and

Fosamax Coffee, orange juice Take without food;
 or any food taken with avoid orange juice or
 the drug can decrease coffee at medication
 availability time

Monoamine oxidase High-tyramine foods Avoid high-tyramine
(MAO) inhibitors (e.g. aged cheese, red foods while taking this
(e.g. Nardil, wine) can lead to drug
Parnate) hypertensive crisis

Synthroid Soybeans, turnips, Avoid making these
(thyroid drug) cabbage family-- foods a routine part
 contain natural of the diet
 goitrogens; oppose
 the effect of

Tetracycline Milk--reduces Avoid taking milk and
(antibiotic) bioavailability by dairy products with
 forming chelates tetracyline, or time
 dairy intake several
 hours apart from

Theophylline Coffee--can increase Avoid coffee while
 serum levels of the taking this drug OR
 drug prescribe according to
 dietary habit

Triamterene, hydroch Large quantities of Moderate high-potassium
lorothiazide potassium-rich foods foods in diet
(potassium-sparing (bananas, oranges,
diuretics) some salt-substitute
 products)--can lead
 to high serum
 potassium levels and
 irregular heartbeat

Include a Food

Sometimes presence of a nutrient of dietary factor improves the
availability of a drug to the body. Furthermore, supplemental sources
of nutrients may help protect against nutritional deficiency caused by
a particular medication. Thus in some cases, the alternate advice
holds: Include a food or nutritional supplement in conjunction with a
particular drug. Here are a few examples:


Oral iron supplement Orange juice or other Take the supplement with
 vitamin C rich food-- a vitamin C rich food
 vitamin C enhances

Steroid drugs; some Stomach upset Take with food


HerbMed[R] Database:

NIH Medline Plus Drug Information:

NIH Office of Dietary Supplements:

Sue Grossbauer is a registered dietitian with more than 10 years of experience managing clinical nutrition, food service and employee training. Her company, The Grossbauer Group in Chesterton, Ind., serves professional associations and private corporations in the foodservice and healthcare industries.
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Title Annotation:Pharmacy
Author:Grossbauer, Sue
Publication:Contemporary Long Term Care
Geographic Code:1USA
Date:Aug 1, 2003
Previous Article:Market leaders.
Next Article:Presenting the evidence: a cost-saving pharmacy solution with long-term results.

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