A pharmacist's look at the supermarket and beyond

Heroic Pharmacy

I’m just back from attending the Annual Meeting of the Arizona Pharmacy Association and the last session that I attended is still rattling around in my head. Martha (Martie) Fankhauser is making good use of her so-called retirement by advocating for a more sane approach to health. She has devoted much study to the ecosystem of our bodies and brains and speaks eloquently of the need to keep some important realities in mind when treating our patients. Basically, she notes 1) the need to have a regular intake of protein (being sure to get all nine essential amino acids), fatty acids, complex carbohydrates, vitamins and minerals, and water. These nutrients provide the building blocks for our physical structures and our neurotransmitters, with the whole process being fueled by carbohydrates; 2) exercise improves the the release of neurotransmitters that contribute to our well-being; 3) during sleep we produce and store neurotransmitters for use during the next day; 4) a healthy endocrine system with the correct balance of hormones helps to properly control our physiology.

It seems that the more we learn of the role that nutritional and lifestyle choices make in disease and drug therapy effectiveness, the more we can glimpse a better pathway to health. It’s really quite amazing that deficiencies of vitamin B-12, folate,iron, or vitamin D may manifest in a variety of negative effects beyond the familiar anemias or bone density issues. Martie showed how many of the enzymes that are needed to synthesize neurotransmitters require these vitamins to function. She also reminded us that despite its name, vitamin D, is actually a hormone. Ergocalciferol, or D2 is less effective than cholecalciferol, D3. Martie is not a fan of the 50,000 unit per capsule that many of us dispense, more often D2 than D3. She prefers a more modest daily intake of about 400 units of D3.* Kind of tucked away in all this is one of the reasons that not all cholesterol is bad. Our bodies convert 7-dehydrocholesterol to cholecalciferol when our skin is exposed to UVB light. That’s D3, humans don’t make D2, so if you are buying a supplement, look for D3 or cholecalciferol.

She pointed to a whole host of issues with nutrients, vitamins and minerals that cry out for pharmacist to learn more about and become better able to help patients take better care of their bodies. I was struck by the courage of her convictions and her heroic stance to educate the health care community and our patients. This is a huge paradigm change for most of us practitioners. Our focus is too often to take a pill, and when we don’t get the desired response, take a different pill or even worse, another pill. Before you know it, we have a patient taking handfuls of drugs every day, some of them working against others. That’s polypharmacy at its worst. There is little in our system of care to help to undo this approach. The economy of health care is dependent on the prescribing of treatments and in modern medicine those treatments are drugs and all too seldom corrective measures in diet and exercise. This is of particular note in the area of behavioral health.

Martie mentioned the example of serotonin, the neurotransmitter considered to be critical to a good mood and sense of happiness. Our body requires the essential amino acid tryptophan in order to produce serotonin. The entire class of antidepressants called SSRIs (Selective Serotonin Reuptake Inhibitors) work by preventing serotonin being reused by our nerve cells. The theory is that by blocking the reuptake, there will be a higher concentration of serotonin to act upon the nerve receptor that improves our mood. As we learn more and more of the physiology involved, it become apparent that this approach is not without its flaws. So having more serotonin in the synapse sounds great but, the longer it stays in that space and not reuptaken into the storage vesicle, the more apt it is to diffuse away from the area of activity or be dismantled into inert by-products that are eliminated (some serotonin may be converted to melatonin to help regulate or sleep cycle). It’s easy to see that if the patient does not have a source of tryptophan, then no new serotonin will be produced. All the SSRIs in the world will not work if there is no serotonin in the neuron! Some sources of tryptophan are red and white meats (beef, pork, chicken), fish and other sea creatures, eggs, and dairy products. Yes! It’s OK to eat eggs again! Other neurotransmitters like dopamine and norepinephrine have analogous biochemical properties and pathways that we are discovering.

Martie has her work cut out for her but her passion for this subject is winning people over every day. It’s a tough challenge. It is difficult to undo the status quo. Patients, caregivers, and providers are too ready to seek an easy answer in a capsule or tablet. Half the commercials on the evening news are for prescription drugs. Expensive prescription drugs. I’ve said many time that I strive mightily to have my pharmacy students think things through before “going to the literature.” They have been taught the pathophysiology of the body and the pharmacokinetics of drugs, but little time is spent on presenting a complete picture of healthy physiology and the pharmacodynamics of the drugs we supply. I just love that Martie pointed out that these are often pharmacodynamic problems. In other words, it’s not what the body does to the drug (pharmacokinetics), its how the drug affects our entire physiology (pharmacodynamics), our bodies and our brains.

This is a huge mountain to not only climb, but to completely relocate! The healthcare industry will need to be overhauled with a new focus on prevention and healthful behaviors, including a fair payment model for those of us that may guide patients to better health (and so less cost in treatments and other interventions), while medical and pharmacy schools must be willing to rely less on the “literature,” where studies are mostly funded by pharmaceutical manufacturers, and more on basic research into physiology and pharmacodynamics. We must find unique ways of disseminating the information that scares the beejeezus out of Big Pharma and Big Med. It seems all our information sources are bought and paid for by the entities that are making billions from the status quo. Pharmacists must be willing to demonstrate that their value is in creating healthier, happier patients, not shoveling more drugs into these patients. We must have the courage to speak up just as Martha Fankhauser is doing. I’ll repeat what she quoted at the start of this talk, “knowledge is power.” Grab that knowledge and use that power. Your patients will love you for it.

There was so much information crammed into her presentation that I am still processing it all. I appreciate all that Martha Fankhauser has done for the profession of pharmacy and I am thankful that we have such a dedicated believer who has the strength of her convictions to be a change advocate for all of us. Such is the practice of heroic pharmacy and Martie is truly one of our heroes.

I do have a few key points left to make, some that are new and some that you may have seen here before…

Remember the three main components of health: Nutrition, Exercise, and Sleep. Patients, ask your pharmacist for any nutritional advice based on the drugs that you are taking.
But, don’t forget the importance of touch and movement. Touching, hugging and yes, sex, are all important to a healthy human being. As far as movement goes, I am reminded to tell all you youngsters that I had to walk across four yards of shag carpet just to change the channel. Do you even know how to change the channel without using the remote? Get up off your ass and move! If it helps, you don’t have to call it exercise. Maybe you’ll sleep better!

Here are the essential amino acids:

The ONLY way to get these protein building blocks is from what you eat. You’ll recall that tryptophan, for instance, is best obtained from animal sources. If you are a vegetarian, please consider adding whey to your diet, it will add the essential amino acids, including tryptophan, that you may not be getting in sufficient amounts. I know it is dairy-sourced, but it can contain up to 10 times the amount of biologically available (you can absorb it) tryptophan when compared gram for gram with even the best plant protein sources. Whey provides all nine essential amino acids. I have no interest in any company selling whey, I do occasionally recommend it to patients that are vegetarian or perhaps lacking sufficient dietary protein.

Avoid nicotine, alcohol, caffeine. I suggest complete avoidance of nicotine (yes, even e-cigs), and drastically limiting your intake of caffeine (check your beverages, it could be hiding in there), and restricting your use of alcohol to a glass of wine less than once a day.

If you think you are a victim of polypharmacy, ask your pharmacist to do a comprehensive review of all of your current meds and supply him or her with a list of non-prescription products and supplements that you use. Allow time for the response to be prepared for you. If you are both pharmacist and patient and are taking a multitude of drugs, ask a trusted colleague to do the med review. You can even make it anonymous.

Changing your evil ways does not have to be a huge undertaking, it can begin with baby steps and be a wonderful journey towards health and happiness.

Always remember that knowledge is power, but not as powerful of love. Love somebody, love yourself.

Thanks for sharing, Martie! I’m waiting for your book!

* My recall of this talk wasn’t quite as good as it may seem. Martie contacted me to say, “I would recommend a higher daily dose of vitamin D3 based on a blood level and most adults need a total daily dose of 5000-6000 IU D3 if they can’t synthesize it via the skin. Some may need higher doses based on risk factors.”

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