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Advice to CDEs: Be proactive, advise patients on dietary supplements
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Dietary supplements are featured in the news regularly; however, much of it is confusing, not only to us as diabetes educators but also to our patients. Headlines are always intended to garner attention by stimulating an emotion in the reader, and stories about health-related issues are no different. All the more newsworthy are the reports of study results that seem to challenge everything we think we know. A premier example would be the latest reports on omega-3 intake. With that in mind, we as diabetes educators should begin to think about our patients and what they may privately decide to do or not to do with the information they get from television shows or their friends down the street.
Drug nutrient depletion
The phenomenon of drug nutrient depletion has surfaced lately with the FDA warnings about magnesium depletion resulting from long-term use of the class of drugs known as proton pump inhibitors, such as omeprazole (Prilosec, AstraZeneca). The Natural Medicines Comprehensive Database has so far identified more than 200 drug nutrient issues and classified them according to severity. Although only 4% of those are considered major, 44% are noted to be moderately severe. We are all familiar with the term “drug interaction,” which describes the ability of one drug (or dietary supplement) to “interact” with another to produce an effect that may alter the desired activity of one or the other drugs, such as the interaction between warfarin and sulfonamides.
Drug-induced nutrient depletion is a separate issue. Some prescription and over-the-counter drugs or dietary supplements have the potential to change the physiology in a way that results in nutrient deficiencies over time. Although many drug interactions occur acutely, drug-induced nutrient depletion is usually a slower process that can become problematic with time. Since nutrient depletion usually occurs slowly, the adverse outcomes that may occur tend to be less pronounced than the adverse outcomes from drug interactions. I will mention just a few of the most noteworthy cases.
James Bennett
The ability of metformin to deplete vitamin B12 levels has been in the product insert for as long as I can remember, and it is estimated by some that as many as 30% of chronic metformin users may be deficient in B12. This deficiency can lead to onset or exacerbation of peripheral neuropathy, obviously an issue for our diabetes patients. As mentioned earlier, members of the class of drugs known as proton pump inhibitors (Prilosec, AstraZeneca; Nexium, AstraZeneca; Protonix, Wyeth Pharmaceuticals; and others) can and often deplete magnesium. The proton pump inhibitors, as well as the H2 antagonists such as ranitidine (Zantac, Boehringer Ingelheim) and others, alter the acidity of the gastrointestinal tract, resulting in changes in the normal flora. Studies are ongoing on how this upsetting of the balance of nature in the GI tract affects the human body.
Additionally, the loop and thiazide diuretics may not only cause loss of sodium and potassium, but also magnesium and thiamin. Statins can interfere with the production of coenzyme Q10 via the same mechanism that makes them beneficial for lowering cholesterol.
Supplements in the news
Although we know that nutrient depletion can occur in patients on long-term drug therapy, the big questions are how significant is the depletion and does it require nutrient supplementation. We must be aware of those that apply to our patients and be proactive in recommending monitoring and optimal supplementation.
I don’t know about you, but most of our patients are confused about current news reports. Here’s a look at just a few:
Calcium
My clientele, both in the community pharmacy operation and in my diabetes self-management program, don’t know what to do about calcium after the latest reports. Half of them stopped all calcium supplements and the other half continue supplementing with 1,200 mg to 1,500 mg of calcium daily. None of them have assessed their dietary intake of calcium or understand how to adjust their diet or supplement to get to the range of daily intake recommended for their particular situation. A large study published in February in BMJ that was quoted in the news found the mortality issue was associated with not only too much calcium intake but also too little (less than 600 mg daily) in women.
Bottom line: After assessing dietary intake, some people, but not everyone, may need to supplement.
Omega-3
What about omega-3 supplementation? Perhaps fish oil sales should not come to an abrupt end. There are long-standing recommendations from the American Heart Association for dietary omega-3 intake and there are still indications for supplementation in certain cases according to the patient’s needs.
Bottom line: Some people, but not everyone, may need to supplement.
Vitamin D
There seems to be one or more reports daily on the connection between low vitamin D levels and some medical conditions. Right now, the only way to answer our patients’ questions is to look at vitamin D levels and supplement appropriately, aiming to correct not only a deficiency (less than 20 ng/mL), but also insufficiency (21 ng/mL to 29 ng/mL) by aiming for a level higher than 30 ng/mL.
Bottom line: Supplement to get to desired levels, which could take 1,000 to 2,000 units of vitamin D2 or D3 daily, in many cases.
Practice pearls
This article is intended to make us curious about the supplement counseling issue. Curiosity will tempt us to look deeper into the subject and be able to advise patients from a knowledge-based standpoint. That requires a study of the current literature and recommendations from all the professional organizations that we trust for guidelines. What is now apparent is that supplementation is certainly not warranted for everyone. On the other hand, we as diabetes educators pride ourselves in our patient-centered approach, and that will require that we understand an individual’s needs and take appropriate measures.