Grocery shopping after a heart attack

Does this seem like a strange title? Well if you or a loved one has experienced a heart attack once back home the undertaking of grocery shopping can go from a one hour task to a two or three-hour task. This is common complaint heard in Cardiac Rehabilitation. Why? The task of determining which foods are to be avoided and what to replace them with takes a great deal of time. Reading the labels for fat and sodium content, determining  vitamin K sources,  or if the food contains grapefruit or others that could interact with medicines takes time. 

Shop the perimeter

Discharge instructions include following a heart healthy diet. For most that means eliminating much of the processed and  pre-packaged foods from the diet, as they are too high in saturated or trans fats, or too high in sodium. The best way to speed this process up is to try to shop the perimeter of the grocery store. Get your fresh fruits and veggies, stop by the butcher and select fresh-cut lean meats, get your low-fat dairy products,and purchase your baked goods that are whole grain, then be done. Eliminate the inner isles of the store (well other than the cleaning isle). The boxed foods are often high in saturated or trans fats because they replace butter. Butter goes rancid quickly and thus the products would have a short shelf life, so they substitute trans and saturated fats so the product can remain on the shelf for a year or more, although eating it reduces your shelf life 🙂

Vitamin K is an issue if you are discharged on the blood thinner Coumadin. While it is not necessary to eliminate vitamin K from the diet, it is important to get approximately the same dosage daily, to help avoid large swings in your INR rates. Try to eat the same portions of vitamin K each day. Many patients report they cannot eat foods with vitamin K, in fact we want them too, but we want them to understand the content and keep it similar from day-to-day. To learn more about Vitamin K and Coumadin click here

Grapefruit, blood oranges are a couple of items that effect the potency of medications and should be avoided at all cost. Statin – cholesterol lowering medications in particular are effected. Know what items contain grapefruit juice and avoid these. For more information about heart medication that interact with grapefruit click here

Sodium is in just about everything in the middle shelves. It is the preservative which again allows for the long shelf life. Avoid foods with 800 milligrams or more per serving. Remember the 1500 milligram daily goal shouldn’t be exceeded. Again if buying fresh foods and not processed is the easiest way to adhere to the guidelines. Learn more about sodium

It gets easier, and takes less time after a while. You learn what brands are best, and where to find them. You try new foods and decide what you like. Some hospitals have grocery store tours with dietitians to help you learn what is marketing and what is healthy.

Common marketing issues where you think you are purchasing healthy foods but are not

Ground turkey. Everyone comes to rehabilitation and tells me they had ground turkey burgers. I challenge them to go back and look at the percentage of fat in the ground turkey. Most of it contains 80% protein 20% fat, that is the same as most hamburger contains. It would be better to eat ground sirloin of 90% protein and 10% fat. Better yet, learn to make bean burgers – super easy to make and much better and less expensive as the pre- packaged bean burgers. Another one that I chuckle at is the milk choices. Patients come in proud they are no longer drinking whole milk, and report they are at 2%. Well I educate them to consider a glass of whole milk is about equal to three restaurant size pats of butter, 2% would equal 2 pats of butter, 1% equals 1, skim equals no saturated fat. Green labels also don’t mean. Peanut butter – read the labels it may say no trans fats, but contains partially hydrogenated oils…hmmmm….not a good choice. Select the peanut butter that is natural the kind that you must stir the oil into the peanut butter. Many foods are labeled trans fat-free, as if it were a recent change to make it healthier, when in fact they never contained trans fats.

A funny story one time I had a very young woman with serious heart disease proudly announce she made a good selection when she picked chicken gravy over beef….missing the point that gravy is fat and salt completely.

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Heart medications that interact with grapefruit

It is grapefruit season but the millions of people who take heart medications and cholesterol lowering medications need to know the interactions can be deadly.

Working in cardiac rehabilitation I found that even though our current knowledge is that these interactions should be avoided, many in the healthcare profession do no give accurate advice. This includes physicians, pharmacist and nurses.  It isn’t  because they are bad or anything, it is simply impossible to keep up with medical information on so many topics. I know many in healthcare that don’t take the time to regularly research and actively keep educated. So that being said here is what you need to know.

What you need to know about consuming grapefruit if on some heart medications:

  • Avoid all grapefruit products this includes the fruit and juice
  • Know what food products contain grapefruit…consider cocktails, soda, mixed fruit juices
  • Timing doesn’t matter if you take the medication and wait, it still can be deadly or cause serious health problems
  • Even if you have been consuming gratefruit products without problems the health issues can occur very suddenly or cumulative

Pomelos and Seville oranges, a type of bitter orange often used to make marmalades and compotes, may have a similar effect.

The  below passages were posted on The Heart. Org and discuss some of the effects including GI Bleeds , Pulmonary toxicity, myopathy, heart failure, death….not things any heart patient needs to occur, simply because they ingested a grapefruit or a glass of grapefruit juice.

Does ingesting a grapefruit amount to the same interaction as drinking the juice? It seems that the juice would represent a more toxic cocktail of furanocoumarins, which are the nasty little compounds found in grapefruit as well as Seville oranges and limes, that inhibit the concentration of cytochrome p450 3A4. The latest report suggests that the effects can range from complete nullification of a drug effect as in clopidogrel to boosting the effects of the drug simvastatin to as much as 330% in the human bloodstream.

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The ramifications of this finding are clear. Who knows how many GI bleeds in the “Blood thinner category” warfarinrivaroxaban trials were due to grapefruit ingestion? Were early compounds yearning for market relegated to the boneyard because of grapefruit-juice–induced toxicity? Did my colleague get sued over statin myopathy because her patient suddenly developed a hankering for grapefruit? Did my patient develop pulmonary toxicity while on amiodarone because his wife bought grapefruit juice for a month because she thought it might be good for him? One will never know, but one should get the hint. We clearly need to warn our patients of this interaction, and trials need to be controlled for grapefruit ingestion when compounds are tested.

There is a smattering of short case reports in the literature describing the grapefruit-drug interaction. In 2009, a report was published in the Southern Medical Journal that described verapamil toxicity in a 42-year-old female who had consumed large amounts of grapefruit juice. In the Annals of French Anesthesiology in 2009 there was a report of a patient who hemorrhaged profusely after taking her vitamin-K antagonist with grapefruit juice.

It is uncertain as to whether the same concerns hold for ingesting the actual fruit as they do for the juice of the grapefruit. In 2010, in Clinical and Experimental Hypertension, a report was published in which a hypertensive male was given 7 oz of grapefruit juice with nifedipine and later with amlodipine. There was no change in plasma concentration of the amlodipine, but the nifedipine concentration increased significantly and resulted in “short-lived” hypotension. Interestingly, they repeated the experiment with ingestion of the actual grapefruit, with no resultant change in concentration or blood pressure.

For now, there are enough data to support the recommendation for banning grapefruit and grapefruit juice altogether from the diets of those on certain cardiovascular medications. For laypersons who read my blog, I’ll add the names under which these compounds are marketed. (For a more complete list, check abcnews.com.) They include:

Rhythm agents:

  • Amiodarone (Pacerone).
  • Dronedarone (Multaq).
  • Quinidine (not commonly prescribed).

 

Cholesterol agents:

  • Atorvastatin (Lipitor).
  • Lovastatin (Mevacor).
  • Simvastatin (Zocor).

The new anticoagulant rivaroxaban (Xarelto), prescribed in placed of warfarin in some.

 

High-blood-pressure meds:

  • Nifedipine (Procardia).
  • Verapamil (Verelan).
  • Felodipine (Plendil).

 

Antiplatelet agents:

  • Ticagrelor (Brilinta).
  • Clopidogrel (Plavix)—in this case, it completely nullifies the effect of Plavix instead of exaggerating it, as in the other meds listed above.

In addition, there is an interaction with the heart-failure diuretic eplerenone (Inspra).

I note that sirolimus is also listed here, and I’m curious about patients with stents coated with sirolimus (the older Cypher stents), but I don’t know of any data or case reports that directly address this issue.

So, all around the world, when medical practitioners open the office door today, we’ll get many questions about grapefruit. Until this week, it simply sat nestled in grocery aisles and holiday fruit baskets, waiting to be lovingly sliced as citrus-laden droplets spray our faces and our taste buds prepared to bask in the glory of its bitter sweetness. It only suffered from unsubstantiated rumors and gossip mongering. But today, we know more. Did the English poet John Milton perhaps know then what we know now when he penned this phrase many years ago? “The fruit of the forbidden tree whose mortal taste brought death into the world and all our woe.”

Alas, until more data are available, my lowly grapefruit, “I must banish thee.”

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