Doi:10.1016/j.jada.2003.08.016

Position of the American Dietetic Association:Integration of medical nutrition therapyand pharmacotherapy POSITION STATEMENT
It is the position of the American Dietetic Association thatthe application of medical nutrition therapy (MNT) and It is the position of the American Dietetic Association that lifestyle counseling as a part of the Nutrition Care Process the application of medical nutrition therapy (MNT) and life- is an integral component of the medical treatment for man- style counseling as a part of the Nutrition Care Process is an agement of specific disease states and conditions and integral component of the medical treatment for management should be the initial step in the management of these situ- of specific disease states and conditions and should be the ations. If optimal control cannot be achieved with MNT initial step in the management of these situations. If optimal alone and concurrent pharmacotherapy is required, then control cannot be achieved with MNT alone and concurrent the Association promotes a team approach to care for cli- pharmacotherapy is required, then The Association promotes ents receiving concurrent MNT and pharmacotherapy and a team approach to care for clients receiving concurrent MNT encourages active collaboration among dietetics profes- and pharmacotherapy and encourages active collaboration sionals and other members of the health care team. among dietetics professionals and other members of thehealth care team. There are a number of medical conditions, Through the nutrition care process (1), medical nutrition many of them chronic, that will respond to MNT and, there- therapy (MNT) is a specific nutrition service and procedure fore, MNT should be the first intervention for these condi- used to treat an illness, injury, or condition. MNT involves an tions. In addition to being a vital element of the optimal man- in-depth nutrition assessment of the patient or client; nutrition agement and control of these conditions, MNT is also a cost- diagnosis; nutrition intervention, which includes diet therapy, effective method of management. However, because of the counseling, or use of specialized nutrition supplements; and long-term nature of these conditions, concurrent pharmaco- nutrition monitoring and evaluation (2). Lifestyle counseling, therapy may become necessary to achieve or maintain opti- as a part of the dietetics professional’s application of the Nutri- mal control. In cases where this is necessary, MNT should tion Care Process, enhances MNT by providing insight into the continue to be an integral component of the therapy because behaviors and/or events that are associated with appropriate as it may complement or enhance the therapeutic effectiveness well as inappropriate eating and exercise behaviors. MNT and of pharmacotherapy, thereby reducing or eliminating the lifestyle counseling are cost-effective means of treating a num- need for multiple medications. The utilization of a coordi- ber of diseases and their symptoms (2-4). However, because of nated multidisciplinary team approach is critical to the suc- the long duration and complexity of some diseases, pharmaco- cess of the concurrent use of MNT and pharmacotherapy be- therapy is usually also necessary to achieve and maintain opti- cause of the long-term duration of the treatments, the mal disease control. Even after the initiation of pharmacother- necessity of monitoring compliance and effectiveness, and apy, MNT should be continued because concurrent use with the likelihood of multiple medication-nutrient interactions.
pharmacotherapy may decrease the amount and/or number of J Am Diet Assoc. 2003;103:1363-1370. medications necessary to achieve optimal disease control (5).
Additionally, concurrent administration of MNT and pharma-cotherapy requires a thorough, individualized medication-nu-trient interaction assessment to identify the potential interac-tions that may occur. This assessment should also include areview of any complementary and alternative medicine (CAM)therapies being utilized to evaluate potential interactions withboth the MNT and pharmacotherapy regimens. Consequently, Copyright 2003 by the American Dietetic Association.
0002-8223/03/10310-0014$30.00/0doi: 10.1053/S0002-8223(03)01222-7 Journal of THE AMERICAN DIETETIC ASSOCIATION / 1363
a comprehensive evaluation requires a coordinated, multidisci- collected in the 1999 and 2002 environmental scans commis- sioned by the American Dietetic Association show that fewcodes were used by health plans in 1999 to report services ROLE OF THE HEALTH CARE TEAM
performed by registered dietitians (13). However, the three By definition, “a collaborative team approach” represents a new CPT codes for MNT provided by a registered dietitian were multidisciplinary group of health care professionals with varied in use by most health plans participating in the 2002 scan.
expertise, working together as a team to aid in the care of the These advances in reimbursement remove barriers and are patient (6). Multidisciplinary teams including a dietetics pro- advantageous to dietetics professionals in private practice and fessional were formed in the late 1970s in the management of those working in physician-managed clinics. Patients are more specialized nutrition support. Subsequently, this multidisci- likely to comply with a physician referral to a dietetics profes- plinary team approach has progressed from the critical care sional if nutrition services are covered by insurance plans.
setting to the care of patients with hyperlipidemia, diabetes,and obesity in outpatient clinics and other private practice set- USING MNT AND PHARMACOTHERAPY
tings. In obesity, the multidisciplinary teams have been ex- MNT and lifestyle counseling, as applied through the Nutrition panded to include clinical psychologists, exercise specialists, Care Process, are effective treatments for many chronic medi- and other allied health professionals. Benefits of such teams cal conditions. Several expert committees or panels recom- have included improved patient safety and clinical outcomes mend MNT and lifestyle changes as the initial intervention for certain chronic conditions (eg, hyperlipidemia, hypertension, Rising health care costs are driving the development of more diabetes) (5,14-16). However, because of the long-term nature comprehensive disease management strategies that address of some of these conditions, pharmacotherapy may also be nec- chronic disease (8). The Disease Management Association of essary to achieve optimal disease control. Risk stratification, America defines disease management as a system of coordi- determination of the degree of risk for adverse events related nated health care interventions and communications for popu- to a medical condition, is often employed to establish the in- lations with conditions in which patients’ self-care efforts are tensity necessary for the initial intervention. For example, significant. It is an organizational model of a holistic approach MNT alone is recommended as the initial interventions for hy- in which health care professionals work together in a coordi- perlipidemia if the low-density lipoprotein cholesterol (LDL-C) nated and cooperative manner to affect an optimal outcome for concentrations are between 100 and 130 mg/dL and the patient a particular patient with a particular disease.
has coronary heart disease (CHD) or CHD risk equivalents Disease management is directed at conditions such as diabe- (16). However, if the LDL-C is above 130 mg/dL and the patient tes, renal disease, hypertension, cardiovascular disease, can- has CHD or CHD risk equivalents, pharmacotherapy should be cer, and obesity. For each condition, diet can be a contributor initiated concurrent with MNT (16). Risk stratification is also as well a therapeutic intervention. This suggests that, for con- promoted for conditions such as hypertension, type 2 diabetes, ditions responsive to MNT, dietetics professionals should be osteoporosis, and obesity. If the response to MNT and lifestyle involved along the entire continuum of care, from program changes alone is not adequate to achieve the desired level of development through implementation. Hence, disease man- disease control, pharmacotherapy can be initiated, increasing agement offers an opportunity for dietetics professionals. Mul- in intensity (ie, increasing the amount of medication pre- tidisciplinary disease management programs aimed at chronic scribed or number of medications prescribed) until optimal multisystem diseases are anticipated to be better accepted by disease control is attained. However, increasing the dose both patients and providers when all relevant professionals are and/or number of medications utilized increases the potential involved in the development of the program (9).
for medication-related adverse effects or medication-nutrient The Diabetes Prevention Program (DPP) demonstrated that interactions. Therefore, ongoing MNT and lifestyle changes are lifestyle interventions can prevent or delay the onset of diabe- critical to the management of chronic diseases.
tes (10). In addition to functioning as DPP lifestyle coaches,registered dietitians assumed roles as case managers and pro- POTENTIAL ADVERSE EFFECTS RELATED TO
gram coordinators, which represent major role expansions for PHARMACOTHERAPY
dietetics professionals working in and with multidisciplinary Adverse effects associated with pharmacotherapy are a com- teams. These role transformations, from clinicians to program mon reason for nonadherence with prescription medications coordinators and case managers, have implications for the vis- (17). For example, drug-induced weight gain has recently been ibility of dietetics professionals in various practice settings recognized as a serious medical problem, compromising the effectiveness of drug therapies (18-23). Drugs used to treat In addition, the growth of managed care has presented di- diabetes and psychiatric, neurologic, and other disorders can etetics professionals with new opportunities for reimburse- cause weight gain. Conversely, other drugs used to treat these ment (11,12). The publication of MNT Current Procedural Ter- disorders are either weight “neutral” or cause weight loss.
minology (CPT) codes and definitions approved by the Studies show that clozapine, a treatment for schizophrenia, American Medical Association and the implementation of and other antipsychotics significantly increase weight, hyper- Medicare Part B reimbursement for diabetes and nondialysis tension, dyslipidemia, and risk for diabetes (18,19). Therefore, kidney disease are also likely to result in expanded coverage of MNT and lifestyle counseling should be a component in the MNT by commercial payers. The American Dietetic Association treatment of patients who take those drugs known to cause sought CPT codes so that registered dietitians could be paid directly for their services. The MNT CPT codes became avail- In addition to adverse effects, other reasons for noncompli- able for use among private sector insurers in November 2000 ance with prescribed medications include socioeconomic sta- and are also required for implementation of the Medicare Part tus, personality, culture, values, mental capacity, understand- B MNT benefit (3). According to Fitzner and colleagues, data ing of the disease, social support systems, and financial factors 1364 / October 2003 Volume 103 Number 10
(24-26). Socioeconomic status has been demonstrated to af- offer protection from the adverse effects associated with cer- fect patients’ ability to self manage their disease, a particularly tain medications (eg, milk thistle seed extract may protect the important parameter in the control and treatment of diabetes liver from the hepatotoxic effects of certain psychotropic med- mellitus, and to result in poor food choices, potentially compro- ications [42]). Even common components of the typical Amer- mising pharmacotherapy and increasing the risk of food-drug ican diet may enhance or interfere with certain medications interactions (25,26). Education has been shown to improve (eg, grapefruit inhibits the oxidative metabolism of some lipid- compliance with therapeutic interventions, reducing the likeli- lowering medications by the intestinal cytochrome P450 3A4 isoenzymes, increasing their bioavailability [43]; high-dose gar- Failure to take medications correctly has been estimated to lic or fish oil supplementation can prolong bleeding time and cost the United States economy $100 billion per year (24). An enhance the action of anticoagulants such as warfarin sodium estimated 40% of patients are expected to experience a thera- [31]). Consequently, health professionals need to have the peutic failure caused by medication-related problems or the knowledge and resources available to evaluate the full range of development of new medical conditions resulting from the potential affects associated with this rapidly growing area.
pharmacotherapy. Because drug compliance rates are esti-mated to be between 50% and 60%, the potential ability of a CHRONIC DISEASE AND MNT
pharmaceutical intervention to treat a disease is frequently The United States Census Bureau reports that, in the year unknown. Dietetics professionals have the expertise to provide 2000, 12.6% of the United States population (approximately the nutrition intervention required to reduce the risk of ad- 34,720,000 people) were 65 years of age or older and 3.3% verse reactions associated with poor food choices.
(approximately 9,093,000 people) were 80 years of age or older(44). These percentages are projected to increase to 20% (ap- USE OF COMPLEMENTARY THERAPIES WITH MNT
proximately 70,265,000 people) and 5.3% (approximately AND PHARMACOTHERAPY
18,620,000 people) of the total US population, respectively, by The use of CAM therapies in the United States is steadily in- the year 2030 (44). A consequence of the aging of the popula- creasing, with, depending on how broadly or narrowly CAM is tion is an increase in the incidence of chronic diseases such as defined, an estimated 6.5% to 43% of the US population using diabetes mellitus, obesity, hypertension, osteoporosis, cardio- some form of CAM (29-31). CAM can include chiropractic, acu- vascular disease, and cerebrovascular disease. Because the on- puncture, massage, herbs, and mind-body therapies as well as set is subtle, chronic diseases tend to be characterized by the use of over-the-counter (OTC) nutritional and dietary sup- symptoms and complications of long duration. As a result, pa- plements (30). The widespread use of herbs and OTC supple- tients with one or more chronic diseases require long-term ments is of concern because of the potential impact on the management, typically under the care of a primary care physi- efficacy of MNT and pharmacotherapy.
cian and a health care team. Although pharmacotherapy is usu- According to the American Dietetic Association MNT evi- ally a part of the therapeutic regimen, the chronic diseases or dence-based guides for practice, dietetics professionals should their symptoms can be managed with nutrition intervention as review use of herbs or nutritional supplements as part of the well; therefore, MNT is an integral part of the recommended in-depth nutrition assessment because of their prevalence of use and the number of potential interactions that may occur Other chronic conditions, such as inflammatory bowel syn- (32-35). Evaluation of these potential interactions should be drome and other conditions that affect the gastrointestinal based on current scientific evidence, which can be a challenge tract, Parkinson’s disease, and seizure disorders that respond given the rate at which new research is being conducted in this to a ketogenic diet, or symptoms associated with these condi- area. However, numerous scientifically based resources are tions also respond to nutrition intervention. However, pharma- available (eg, The Complete German Commission E Mono- cotherapy in addition to nutrition intervention is usually re- graphs: Therapeutic Guide to Herbal Medicines [36]; Herbal quired for optimal control of the condition and associated Medicine: Expanded Commission E Monographs [37]; Herb symptoms. Patients with more complex chronic conditions that Contraindications and Drug Interactions [38]; The Health involve organ system dysfunction, such as chronic obstruction Professional’s Guide to Popular Dietary Supplements [31]; pulmonary disease, congestive heart failure, renal disease, liver Physician’s Desk Reference for Herbal Medicines [39]; Phy- disease, cancer, and immune system diseases, including Hu- sician’s Desk Reference for Nonprescription Drugs and Di- man Immunodeficiency Virus/Acquired Immunodeficiency etary Supplements [40]; and Physician’s Desk Reference for Syndrome, will require pharmacologic intervention, although Nutritional Supplements [41]).
concurrent MNT is essential to optimize the effectiveness of The interactions between CAM therapies and MNT or phar- macotherapy can be either positive or negative. Herbs and nu- The concurrent use of MNT and pharmacotherapy to treat tritional or dietary supplements may increase or decrease the chronic conditions is, by necessity, of long duration. Conse- bioavailability of medications or other nutrients (eg, psyllium quently, monitoring patients to ensure adherence to the pre- can delay the intestinal absorption of medications, minerals, or scribed therapy and verify its effectiveness is a continuous pro- vitamins taken at the same time [36]) or have antagonistic af- cess that is most efficiently performed by a health care team.
fects (eg, kava extract may reduce the efficacy of levodopa in Patients should be encouraged to continue their MNT regimen, the treatment of Parkinson’s disease [42]). Additionally, these including recommended lifestyle changes such as food choice same products may have additive effects (eg, kava extract and changes and changes in exercise, even when pharmacotherapy diazepam taken together at normal doses can result in lethargy is necessary to achieve desired disease control. The continued and disorientation [42]) or enhance the action of medications inclusion of MNT as part of the multidisciplinary treatment plan (eg, consumption of bromelain may increase the anticoagulant can result in effective disease control with less intense phar- effects of anticoagulant medications [42]) by mechanisms macotherapy (eg, lower doses of medications or monotherapy other than affects on bioavailability. Some products may also instead of polytherapy) (5). As a result, the cost of the therapy Journal of THE AMERICAN DIETETIC ASSOCIATION / 1365
will be lower, and the incidence of side effects will be reduced.
fessionals, is essential for enhancing the effectiveness of these These factors may, in turn, improve adherence with the overall drugs and for reducing their adverse effects (61-63).
therapeutic regimen because two of the most common reasons The support of the entire health care team, including the for not taking medications as prescribed are the cost of and the dietetics professional, is instrumental for patient self-care com- adverse effects associated with the medication (17).
petence. Patients should be capable of knowing how to useblood glucose data to adjust food intake, exercise, or pharma- DIABETES MELLITUS AND COMPLICATIONS
cologic therapy to achieve their therapeutic goals.
Diabetes mellitus is a group of metabolic diseases character- Advances in molecular biology technology and identification ized by hyperglycemia resulting from defects in insulin secre- of new drug targets are expected to yield novel pharmacologic tion, insulin action, or both. The chronic hyperglycemia of dia- agents for blood glucose control. Examples of new drugs under betes is associated with long-term damage, dysfunction, and investigation are amylin and its synthetic analog pramlintide, failure of various organs, especially the eyes, kidneys, nerves, glucagon-like peptide-1 (GLP-1), and dipeptidyl peptidase IV heart, and blood vessels (45). The most common forms of dia- inhibitors. These agents moderate postprandial glucose excur- betes are type 1 and type 2, type 1 being dependent upon sions by delaying gastric emptying (64-66). Although these drugs are expected to be more effective and to produce fewer Type 2 diabetes has reached epidemic proportion (46,47) adverse effects, dietetics professionals will continue to need to and is expected to increase by 165% from 2000 to 2050 (48).
alert patients about the ongoing importance of lifestyle inter- The annual cost of diabetes in medical expenditures and lost ventions for optimal glucose control and the possible nutrition- productivity reflects these demographics, climbing from $98 ally related effects of these drugs.
billion in 1997 to $132 billion in 2002 (49). Individuals over 45 In addition to diabetes mellitus types 1 and 2, MNT has been years of age and who have a BMI Ն 25 kg/m2, growing segments demonstrated to be effective for other conditions associated of the population, are at increased risk of developing type 2 with insulin resistance. One example is polycystic ovary syn- diabetes mellitus (45). An estimated 80% of patients with type drome (PCOS), a common endocrine disorder in women of 2 diabetes mellitus are overweight or obese (50,51). The alarm- reproductive age with primary manifestations of infertility, ing emergence of childhood and adolescent type 2 diabetes is menstrual dysfunction, and clinical or biochemical hyperan- correlated with the increasing incidence of severe obesity in drogenism. Obesity is common in PCOS, but not universal, and this age group (52,53). Prevention of excess weight gain and is present in approximately 10% to 50% of women of reproduc- obesity is critical to reverse these trends.
tive age. Weight loss will reverse the insulin resistance and MNT is an important component in the prevention, delay, associated reproductive dysfunction and lessen the risk for de- and treatment of type 1 and type 2 diabetes (14,15,48,54-56).
veloping type 2 diabetes and long-term cardiovascular disease Behavior changes, including diet and exercise, will prevent and (67,68). Hyperglycemia and insulin resistance are also com- delay the development of type 2 diabetes, with the primary mon in critically ill patients, even when there has been no prior objective being a reduction in body weight (14,57-59). MNT for history of diabetes. Recent studies have reported that the use people with diabetes should be individualized, with consider- of intensive insulin therapy to maintain blood glucose at a level ation given to each individual’s usual eating habits, metabolic that does not exceed 110 mg per deciliter can substantially profile, treatment goals, and desired outcomes (55). Monitor- reduce mortality and morbidity in patients admitted to the in- ing of metabolic parameters, including glucose, HbA1c, lipids, tensive care unit (69,70). Additional studies are needed to de- blood pressure, body weight, and renal function, when appro- termine whether MNT in conjunction with intensive insulin priate, as well as quality of life is essential to assess the need for therapy is beneficial to patient outcomes.
changes in therapy and to ensure successful outcomes. Ongo-ing nutrition self-management education and care need to be OBESITY AND COMPLICATIONS
available for individuals with diabetes. For a complete listing of Obesity has reached epidemic proportions in the United States.
current evidence-based scientific rankings of MNT guidelines It is estimated that 50% to 65% of the US population is either using the recently published American Diabetes Association overweight or obese (21,71-75). Environmental factors such as grading system, refer to Franz and colleagues (54).
a decrease in physical activity and increased food intake are When blood glucose levels cannot be adequately controlled attributed to this trend (74,76-80). Obesity is associated with by lifestyle interventions, pharmacologic intervention is indi- high blood pressure, type 2 diabetes, insulin resistance, hyper- cated. Oral hypoglycemic agents such as the sulfonylureas, insulinemia, dyslipidemia, coronary heart disease, gallbladder nateglinides, biquanides, ␣-glucosidase inhibitors, thiazo- disease, some forms of cancer, sleep apnea, and other chronic lidinediones, and combinations of these drugs are used before progressing to exogenous insulin and insulin analogs when In 2000, the obesity market generated over $426 million in pancreatic beta cells become exhausted in the later stages of drug sales in the United States (81). The marked growth in this the disease. The modes of action of these drugs include en- potential patient population will be a main driver in estimating hancing insulin sensitivity, inhibition of hepatic glucose pro- the obesity market for pharmaceutic sales. Sales are projected duction, stimulation of insulin secretion, and inhibition of in- testinal glucose absorption. However, several of these agents Antiobesity agents target appetite suppression, increased thermogenesis, and/or reduced nutrient absorption to produce weight gain (21,22,60), making weight loss more difficult for negative energy balance (82-84). Sibutramine and orlistat are overweight and obese patients. Alternative agents that may the only two antiobesity agents currently approved for long- promote weight loss or be weight neutral include metformin, term use. Sibutramine suppresses appetite and causes an in- acarbose, miglitol and the weight loss drugs orlistat and sib- crease in metabolic rate (85,86). Orlistat, a lipase inhibitor, utramine. MNT, combined with a thorough understanding of reduces fat digestion and absorption. Fenfluramine-phenter- medication-nutrient interactions, as practiced by dietetics pro- mine, an extremely effective agent, was removed from the 1366 / October 2003 Volume 103 Number 10
market because of serious heart disease. The FDA-approved tension increases, the result being that less than 20% of people over-the-counter (OTC) appetite suppressant, phenylpropa- over 70 years of age having a blood pressure in the optimal nolamine, was removed from the market in 2000 because of an range (90). For many years, pharmacotherapy was the primary association of strokes with its use in women.
therapeutic regimen employed to lower blood pressure (90), Dietary supplements, herbal preparations, and other OTC and, for many patients, poor control on a single medication products are also used as antiobesity agents. Convincing data resulted in polypharmacy (91). However, recent research sup- that demonstrate either the efficacy or safety of these products ports the use of MNT and lifestyle changes as concurrent inter- are essentially nonexistent. The National Institute of Health ventions with pharmacotherapy in the treatment of hyperten- does not recommend them as part of a weight-loss program sion, and, in some cases, MNT should be the primary because of potentially harmful effects and unpredictable levels of the purported active ingredients (82). OTC compounds that The most recent reports from the Joint National Committee may have some effect are 5-HTP/tryptophas, calcium/vitamin (JNC) on Prevention, Detection, Evaluation, and Treatment of D, cimetidine, ephedrine, and teas (87). Those with question- High Blood Pressure recommended the reduction of dietary able or no weight loss effect are chitosan, chromium, garcinia sodium intake, weight loss, and increased physical activity as initial effective methods of reducing blood pressure and pro- Drugs approved for disease indications other than obesity, posed them as the first steps in the treatment of hypertension.
such as depression, epilepsy, and diabetes, are prescribed and Pharmacologic therapy would be initiated only if the goal blood are under clinical investigation as antiobesity agents (82-84).
pressure level is not obtained with MNT and lifestyle changes Bupropian use is associated with weight loss and is being inves-tigated in clinical trials as an antiobesity agent. Selective sero- alone (5,93). Additionally, the 6th report from the JNC recom- tonin-reuptake inhibitors (SSRIs) such as sertraline and fluox- mends increasing dietary potassium intake and a desirable di- etine have very limited effects on appetite (82,88). The etary pattern that includes increased vegetable and fruit con- R-fluoxetine drug development program was discontinued af- sumption. These MNT interventions were also supported by ter some subjects developed increases in QTc prolongation, a the Dietary Approaches to Stop Hypertension (DASH) study symptom associated with heart arrhythmias. Anticonvulsants (5,92). Metaanalyses of randomized clinical trials have re- such as topiramate reduce food intake and cause weight loss.
ported systolic and diastolic blood pressure reductions of ap- Some antidiabetes agents such metformin can cause or help to proximately 4 and 2 mm Hg in hypertensive patients with a maintain weight loss. Other drugs used for weight loss, but reduced sodium intake (94) and reductions of 1.6 and 1.1 mm approved for indications other than weight loss, are diazoxide, Hg, respectively, in overweight and obese patients with each diethylpropion, naltrexone, phendimetrazine, and phenter- kilogram of weight lost (95). The DASH study also provided mine (81,82,89). New drug targets are likely to result in the convincing evidence that MNT is a viable first step in the ther- development of novel antiobesity agents that are more effec- apeutic regimen to lower hypertension. Using a dietary pattern that emphasized vegetables, fruits, and low-fat dairy products, Tens of new agents are in clinical trial, such as cabergoline (a nonhypertensive participants decreased their systolic and dia- dopamine receptor agonist), cannabinoid antagonists, ␤-3 ad- stolic blood pressure by 3.5 and 2.1 mm Hg, respectively, and renergic agonists, ghrelin, cholecystokinin-A agonists, and hu- hypertensive participants decreased their values by 11.4 and man growth hormone peptide analogs (81,82,84). Leptin has failed as an antiobesity agent in human clinical trials. The ob- If MNT and lifestyle changes alone fail to lower the blood servation that obese individuals already have elevated circulat- pressure to the goal level, then pharmacotherapy is indicated.
ing leptin levels, indicating leptin resistance, supports ongoing However, patients should be encouraged to continue MNT and research to determine whether agents that modulate leptin lifestyle changes because these might result in fewer medica- receptor response to leptin will produce weight loss.
tions and lower dosages being required to achieve optimal Increasing physical activity and decreasing energy intake is blood pressure control (5). Patients on pharmacotherapy considered the most effective and lasting method of losing should be monitored on a regular basis by a health care team weight and maintaining weight loss (72,83). Many environmen- because most of the medications used to treat hypertension tal and behavioral factors such as decreased physical activity, have at least one nutrition-related side effect. Thiazide and large portion sizes, and foods high in caloric density are coun- loop diuretics, which block the resorption of sodium, also cause terproductive to this approach (74,76-80). The US government a concurrent loss of potassium, magnesium, and zinc and, in the is taking action to identify strategies to change these factors case of loop diuretics, calcium (43). Conversely, potassium- and to reverse the alarming trends in overweight and obesity sparing diuretics exchange potassium for sodium, resulting in Dietetics professionals play an integral role, which is multi- an increase in serum potassium concentrations and a need to faceted and cannot be understated, in addressing the problem monitor potassium intake to prevent hyperkalemia (43). Com- of obesity in the United States. Their knowledge and skills in pounds in grapefruit magnify the action of calcium channel lifestyle counseling and in managing nutrition-related side ef- blockers and should, therefore, be avoided by patients taking fects associated with prescription and OTC antiobesity agents these medications (43). Angiotensin-converting enzyme inhib- and bariatric surgery places them in a unique position to edu- itors and ␣-blockers can cause glucose intolerance (43). The cate the public and other health care practitioners in the pre- ␣-blockers can also produce hyperlipidemia (43). If mono- therapy fails to result in a desirable blood pressure, combina-tion therapy is a possibility, resulting in multiple medication/ HYPERTENSION
nutrient interactions. Consequently, a qualified dietetics Approximately 43 million people in the US population, or 24%, professional should be a member of the health care team that have hypertension, and, as people age, the incidence of hyper- Journal of THE AMERICAN DIETETIC ASSOCIATION / 1367
HYPERLIPIDEMIA
P450 3A4 isoenzymes. The bile acid sequestrants (resins) can According to the American Heart Association, coronary heart also decrease the absorption of calcium; iron; zinc; magnesium; disease (CHD) is the most frequent cause of death among ␤-carotene; folate; and vitamins A, D, E, and K (43). Because of adults in the United States, accounting for one of every five these medication-nutrient interactions related to pharmaco- deaths. Approximately 62 million Americans are estimated to therapy for hyperlipidemia, continued follow-up by a dietetics have cardiovascular disease, and, of these individuals, 650,000 people will have an initial myocardial infarction (MI) and450,000 will have a recurrent MI each year (96). With an esti- CONCLUSIONS
mated total annual cost of $111.8 million because of CHD alone MNT and lifestyle changes are vital components in the success- (approximately 12 million of the 62 million with cardiovascular ful treatment of numerous chronic medical conditions. Al- disease have diagnosed CHD), the economic consequences as- though adherence to MNT and lifestyle changes may prevent or sociated with this disease are stunning (96). Of this total, $58.2 delay the necessity of pharmacotherapy, the successful man- billion is due to direct medical costs, including hospitalization, agement of some conditions will require concurrent therapy.
long-term care, health professional fees, medications, and The increased use of complementary alternative medicine home health care, and $53.6 billion is due to indirect costs such therapies by the public also adds complexity to the manage- as lost productivity and premature mortality (96).
ment of many of these conditions. Consequently, a thorough The role of diet in the development of hyperlipidemia, the evaluation and frequent monitoring by a multidisciplinary first step in developing cardiovascular disease and, more spe- health care team, including dietetics professionals, is the most cifically, CHD, has long been recognized. The Third Report of effective means of helping the patient achieve optimal long- the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults (Adult Treatment Panel III) recommendsMNT as the first line of treatment for most individuals with References
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cost savings of $60,561 or $904 per patient.
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MNT and pharmacotherapy for those patients at high risk for their view on nutrition service coverage? J Am Diet Assoc. 2003;103:157-161.
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cotherapy components of their own, along with MNT and phar- Cholesterol in Adults. Executive summary of the third report of the National macotherapy for the treatment of the CHD, emphasizes the Cholesterol Education Program (NCEP) expert panel on detection, evaluation, need for long-term monitoring by a multidisciplinary health and treatment of high blood cholesterol in adults (Adult Treatment Panel III).
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79. Nestle M. Increasing portion sizes in American diets: More calories, more
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81. Farrigan C, Pang K. Obesity market overview. Nat Rev Drug Discov.
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84. Bray GA, Greenway FL. Current and potential drugs for treatment of
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St. Louis, MO; Mary K Russell, MS, RD, Duke University Hospi- 88. Annual Drugs in Development Issue, Part III. Compounds no longer under
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30, 2003.
89. Annual Drugs in Development Report, Part II. Pipeline Drugs. Available at:
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93. JNC V- Joint National Committee on Prevention, Detection, Evaluation,
lyn, NY); Janet W. Gloeckner, PhD, RD (James Madison Uni- and Treatment of High Blood Pressure. The Fifth Report of the Joint National versity, Harrisonburg, VA); Paula Davis McCallum, MS, RD Committee on Prevention, Detection, Evaluation, and Treatment of High (Advantage Nutrition, Ltd, Summerfield, NC); Pam Michael, Blood Pressure. Arch Intern Med. 1993;153:154-183.
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Chicago, IL); Naveena Reddy, MS, RD (Olathe Medical Center, Dallas, TX: American Heart Association; 2002.
97. Sikand G, Kashyap ML, Yang I. Medical Nutrition Therapy lowers serum
cholesterol and saves medication costs in men with hypercholesterolemia.
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Association Positions Committee Workgroup: 98. Sikand G, Kashyap ML, Wong ND, Hsu JC. Dietitian intervention improves
lipid values and saves medication costs in men with combined hyperlipidemia
Evelyn Enrione, PhD, RD (chair), Abby Bloch, PhD, RD, FADA, and a history of niacin noncompliance. J Am Diet Assoc. 2000;100:218-224.
Martina Cartwright, PhD, RD (content advisor) 1370 / October 2003 Volume 103 Number 10

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