Pharmacists spend much of their days conducting patient consultations but sometimes forget to focus on nutrition. As many pharmacists will remember from school, nutrition plays a big role not only in helping patients obtain certain values when managing disease states but also in improving their overall health. This article looks at 3 common disease states and the main nutritional counseling points that pharmacists should share with patients.

DIABETES
All patients with diabetes should receive individualized medical nutrition therapy. In fact, pharmacists can specialize in nutrition and obtain a certification. Discuss different diet plans with patients, such as the Dietary Approach to Stop Hypertension (DASH) diet, which has demonstrated significant benefits for people managing diabetes, though the plan is not a good match for everyone’s lifestyle. Those with diabetes may also benefit from a low-carbohydrate or vegan diet, and they should consume increased amounts of omega-3 docosahexaenoic and eicosapentaenoic acid contained in fatty fish at least twice a week.1 Patients may also benefit from taking flaxseed oil and soy supplements, which can help regulate blood glucose levels. Pharmacists should advise all patients with diabetes to avoid sugar-sweetened beverages and trans fats. Most people with diabetes take metformin, which is known to decrease vitamins such as B12, and clinicians should also discuss the adverse effects with patients at the consultation.2

DYSLIPIDEMIA
Diet also plays a large role in the treatment of dyslipidemia and can negatively or positively affect cholesterol levels, so clinicians should convey the importance of nutrition during one-on-one sessions with patients. Triglycerides can increase when a patient consumes too much alcohol or refined carbohydrates, potentially leading to diseases such as pancreatitis. A patient solely on a low-fat diet may also see a significant increase in triglycerides.3 Moreover, patients’ low-density lipoprotein (LDL) levels can easily increase when they consume an excessive amount of saturated or trans fats from processed foods.

In lowering cholesterol, the recommended dietary regimen for those with dyslipidemia is similar to the DASH diet, as patients should still eat a lot of high-fiber foods, such as fruits and vegetables. Fish intake is strongly advised, especially oily fish such as mackerel and salmon, as they significantly decrease LDL and triglyceride levels. Advise patients to stick to lean meats and aim for just 6% of calories from saturated fats. Avocados are considered a key food in lowering patients’ LDL cholesterol levels and increasing their high-density lipoprotein levels as well. In addition, eating 2 to 3 servings a day of nuts, especially almonds and walnuts, is highly recommended because they can also lower LDL levels. Remember to keep patients’ drug regimens in mind, as most patients will be taking statins, which are known to decrease coenzyme Q10 (CoQ10). As such, also discuss the use of supplements to improve overall function and reduce the potential adverse effect of muscle pain.

HYPERTENSION
High blood pressure (HBP) is the most common disease state managed in primary care. Most patients believe that just taking a pill will move their blood pressure (BP) back into recommended ranges. Some patients even end up on multiple BP medications to try to achieve a level below 140/90 mm Hg. But patients fail to realize how important lifestyle management is in the treatment of HBP, and health care providers should relay this important information to them.

Pharmacists should discuss the DASH diet with patients who struggle with HBP. This diet has been shown to prevent and treat HBP without the use of medication and also lowers the occurrence of other disease states, such as cancer, heart failure, and stroke. The DASH diet emphasizes fish, fruit, low-fat dairy products, nuts, poultry, vegetables, and whole grains.

Accordingly, patients on this diet regimen should consume:
  • 2 to 3 servings of fat-free or low-fat dairy, including cheese, milk, and yogurt. Patients should still be mindful when consuming cheese, which can be high in sodium.
  • 2 servings of fats and oils, as fats can help the body absorb more vitamins. Patients should avoid trans fats, which are found in processed foods such as hot dogs.
  • No more than 6 servings of fish or lean meat. For patients who consume fish, herring, salmon, and tuna are preferred, as they are considered heart healthy. When consuming meat, patients should avoid frying foods and stick to baking or grilling.
  • 4 to 5 servings of fruits and vegetables per day. Patients should consume fruits with the peels when possible, as they contain additional nutrients. Leafy greens are also high in fiber.
  • 4 to 5 servings of nuts or seeds per week. These include almonds, kidney beans, and sunflower seeds, which not only are a good source of fiber but also provide plenty of magnesium, potassium, and protein.
  • No more than 1500 mg of sodium per day.4 Pharmacists should tell patients to look for foods whose packaging indicates low sodium or no salt added.
  • No more than 5 servings of sweets per week. When eating sweets, patients should look for fat-free or low-fat options when possible. Many products have artificial sweeteners, which can help cut down on calories.
  • 6 to 8 servings of whole grains per day. These include cereal, pasta, rice, and whole wheat bread. Advise patients to avoid refined grains, as they do not contain the same amount of fiber as whole grains.
The DASH diet does not focus on alcohol or caffeine consumption, but pharmacists should counsel patients on how these factors increase BP. Women with HBP should limit alcoholic beverages to 1 per day, and men with HBP should have no more than 2.

The DASH diet has been shown to significantly decrease BP over time, starting as early as 2 weeks after a patient starts the diet, and it can even lower the systolic BP number by 14 points if followed correctly. Study results have also shown that the DASH diet decreases the probability of heart failure.5

Lastly, health care providers should be aware of patients’ drugs, as some medications can deplete certain nutrients and vitamins that the body needs. For instance, angiotensin-converting enzyme inhibitors are known for depleting zinc. So, when counseling a patient on lisinopril, a pharmacist should discuss not only following the DASH diet but also taking a zinc supplement or eating foods high in zinc, such as meat or shellfish. β-Blockers also used to manage BP can deplete CoQ10, which can be found in OTC vitamins, and this represents another good counseling point, as CoQ10 improves heart health and regulates blood sugar. When dispensing certain drugs, especially those that can retain a patient’s potassium, clinicians should also discuss electrolytes as well as symptoms of hyperkalemia.

CONCLUSION
When visiting a pharmacy, patients do not typically think to ask about diet and nutrition. Most people do not understand how big a role dietary regimens play in their health when managing conditions. The 3 disease states discussed above are treated in primary care, and all have similar dietary recommendations and requirements. As health care providers, pharmacists must provide patients with this information, as it can significantly improve quality of life. Nutrition can help prevent and treat many other disease states as well. When counseling patients, pharmacists, as the most accessible health care providers, should consider themselves not only experts in medication but nutrition as well.
 
Shelby Leheny, PharmD, is a pharmacy manager for CVS Health in Bedford, Ohio.

REFERENCES
  1. American Diabetes Association. Standards of medical care in diabetes—2016. Dia- betes Care. 2016;39(suppl 1):S1-S112.
  2. Handelsman Y, Bloomgarden ZT, Grunberger G, et al. American Association of Clinical Endocrinologists and American College of Endocrinology—clinical practice guidelines for developing a diabetes mellitus comprehensive care plan. Endocr Pract. 2015:21(suppl 1):1-87. doi: 10.4158/EP15672.GL.
  3. Eckel RH, Jakicic JM, Ard JD, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American Col- lege of Cardiology/American Heart Association Task Force on Practice Guidelines [erratum in Circulation. 2014;129(25)(suppl 2):S100-101] [erratum in Circulation. 2015;131(4):e326]. Circulation. 2014;129(25)(suppl 2):S76-S99. doi: 10.1161/01. cir.0000437740.48606.d1.
  4. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the manage- ment of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi: 10.1001/ jama.2013.284427.
  5. Eckel RH, Jakicic JM, Ard JD; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Car- diology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25)(suppl 2):S79-S99. doi: 10.1161/01.cir.0000437740.48606.d1.