Pharmacist Focus on Patient Nutrition—Let`s Get America Healthy

This year has been very difficult for many individuals around the world. Associated with the COVID-19 pandemic, many persons have had loved ones or friends pass away, lost their jobs, developed mental illness, and as such, have developed a dread of the future. How can we as health professionals make the U.S. healthy? One way is for us to focus on the many aspects of the social determinants of health. The one social issue that maybe more important to individual health is nutrition. Many chronic conditions such as obesity, diabetes, and high blood pressure, along with half of all deaths in the US, are related to diet.¹   

Diet makes a difference. Overconsumption of processed meats, high consumption of sugar-sweetened beverages, and insufficient intake of fruits, vegetables, and whole grains contribute to higher mortality and morbidity.² There are significant differences in individual biological responses to diet. This necessitates that one-size-fit-all approach will not work. The National Institutes of Health (NIH) is leading the effort to advance “precision nutrition.” The field of precision medicine aims to understand the health effects of complex interplay between genetics, the microbiome, antibiotic and probiotic use, metabolism, food environment, physical activity, and the economic, social and behavioral characteristics of the individual.³ The 2020-2030 NIH research strategic plan for NIH Nutrition Research is certainly welcome but will take many years to provide needed data.   

Malnutrition is an important prognostic factor for disease.⁴ It is independent of common cardiovascular risk factors such as BMI or LVEF. A recent study in 5,062 consecutive patients with acute coronary syndrome (ACS) applied several survey instruments (e.g., Controlling Nutritional Status [CONUT], Nutritional Risk Index [NRI], and Prognostic Nutritional Index [PNI]).⁵ The findings showed malnutrition was common among patients with ACS and was strongly associated with increased mortality and cardiovascular events.   

Food insecurity, defined as a lack of immediate access to fresh, health, and affordable food, may be a reason for increased all-cause and cardiovascular mortality. A 2020 study published in the Journal of the American Heart Association in found in 27,198 U.S. adults ≥ 40 years of age who participated in the US National and Health and Nutrition Examination Survey from 1999 to 2014 showed that food insecurity status had a higher risk of all-cause and cardiovascular mortality.⁶  In comparison between with food insecurity, the multivariable-adjusted (adjustment for age, sex, race/ethnicity, education, income, dietary, and life-style factors) was HR 1.32 (95% CI: 1.07-1.62) for all-cause mortality, and 1.53 (95% CI: 1.04-2.26) for cardiovascular mortality with those with high-food security.  

The importance of these research studies, especially at this time of year, shows that patients may be in economic distress. If in distress, the patient (and his/her family) may be deciding between affording their medications or buying food.  Non-adherence to medications may point to economic distress with food insecurity. The key is to focus on the “individual”. This is where the community pharmacists can play a major role. We see patients on a more regular basis than any other health professional. Talk to patients that are non-adherent to medications, especially cardiovascular medications, about the reasons for non-adherence. In doing so, you may be saving a life!

Mark A. Munger, PharmD, FCCP, FACC, is a professor of pharmacotherapy and adjunct professor of internal medicine, at the University of Utah, where he also serves as the associate dean of Academic Affairs for the College of Pharmacy.

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References

1. Micha R, Peñalvo JL, Cudhea F.  Association of dietary factors and mortality from heart disease, stroke and type 2 diabetes in the United States.  JAMA. 2017;317(9):912-924. doi:10.1001/jama.2017.0947
2. Bacon, soda, and too few nuts tied to big portion of US deaths. https://www.statnews.com/2017/03/07/bacon-soda-nuts-death/  Access 12/2020
3. Rodgers GP, Collins FS. Precision nutrition-the answer to “What to Eat to Stay Healthy”. JAMA 324(8):735-6.
4. Freeman AM, Morris PB, Barnared N, et al. Trending cardiovascular nutrition controversies.  JACC 2017;69:1172-87.
5. Raposeiras S, Assi EA, Fernandez MC, et al. Prevalence and prognostic significance of malnutrition in patients with acute coronary syndrome. JACC 2020;76(7):828-40.
6. Sun Y, Liu B, Rong S, et al. Food insecurity is associated with cardiovascular and all-cause mortality among adults in the United States.  JAHA 2020:9:e0114629.  DOI: 10:1161/JAHA.119.014629