Mechanisms and consequences
Supported by policies, practices and programs, harm minimisation is essentially a philosophy, in a range of sectors, to minimise harm rather than to prevent harm.
Harm minimisation applications
Harm minimisation due to harmful substances or behaviours, can be achieved by the introduction of programs and practices that focus on –
- Demand – reducing ease of accessibility, information and awareness campaigns, treatment programs, etc;
- Supply – reducing ease of availability such as border controls and purchasing periods, regulations for defined access, substance intercepts such as seizures and arrests, substance location identification such as waste water analysis, defined minimum purchasing age, etc;
- Harm – supporting behaviour change such as needle exchange programs, opioid-dependence treatment programs, sobering up services, safe injection sites, safe sex programs, drink-driving messages, slip slop slap programs, sunscreen campaigns, mandatory seat belts, road and vehicle speed limits, etc.
“Harms” can include –
- Health – injury, chronic conditions, preventable diseases, mental health problems, road trauma, etc;
- Social – crime, intergenerational trauma, domestic and family violence, child protection, etc;
- Economic – healthcare costs, law enforcement costs, reduced productivity costs, criminal activity consequences, etc.
Harm minimisation strategies target specific issues — often with specific population groups — and develop strategies to minimise the harm caused by the behaviour. If we consider pharmaconutrition, then there are groups of people who are prescribed specific drugs known to confer both benefits and harms, and the harm minimisation concept could be utilised to optimise their health outcomes.
Harm minimisation and clinical application
Currently the impact of prescribed medications on nutritional status, and the impact of nutrition factors on the effects of prescribed medications is considered to be a clinical-only issue. However, it is an issue that could be included in the harm minimisation concept, particularly in the areas of health and economics.
EXAMPLE – Metformin and thiamine
Issue. We know that thiamine and metformin compete for absorption, distribution and excretion as both utilise the same transporters; whichever substance occupies the transporter first means the other substance cannot.
Target Group. People diagnosed with non-insulin dependent diabetes and prescribed metformin.
Strategies. The distribution of education material through diabetes support groups, diabetes clinics, and GP and Endocrinologist waiting rooms. Content would include advice regarding the importance of monitoring thiamine levels on a regular basis, such as annually, whilst metformin is prescribed. This strategy also indirectly informs and reinforces to the GPs and Endocrinologists the importance of regular monitoring of thiamine status.
Outcome – this is a low-cost strategy that can be broadly distributed to the target group at relatively low cost. It also means earlier intervention in delaying/minimising thiamine deficiency-induced outcomes in those who are prescribed metformin for the management of their diabetes.
The concept can be applied to other discreet, identifiable groups such as those with parkinsons disease, epilepsy, mental health, and many others.
Clinical Questions
What actions will you initiate to increase awareness of importance of pharmaconutrition – will you –
- develop leaflets for those in your care with discreet chronic illness and prescribed specific medications?
- speak to a range of chronic unwellness groups about the importance of monitoring nutritional factors impacted by their prescribed medications?
- organise a half-day education session for health professionals, with a range of topics relating to medicine and nutrition and include a specific presentation on pharmaconutrition?
- schedule a “pharmaconutrition year” whereby every month there is as awareness-creating strategy such as a poster campaign, editorial in the local newspaper, stall at a local Festival/Show, request your local MP to fund a mailout, etc, targeting both the community and health sector?
This is based on current research. Your choice is whether to include this information into your clinical practice before it is integrated into Clinical Practice Guidelines.
Conclusions
Pharmaconutrition can fit nicely into the harm minimisation concept.
Case study
The comments refer to the drug-nutrient, drug-food, and PharmacoNutrition effects only.
Data summary
Medical History with Nutritional Aspect
Biochemistry with Pharmaconutritional Consequences
No recent relevant biochemistry available.
Medications That May Adversely Affect Nutritional Status
Biochemistry comments
No recent relevant biochemistry available. Advisable to check plasma proteins (albumin, total proteins) as they are the primary transporters for five of the prescribed drugs and hypoproteinaemia may alter their effects and side effects.
Glycaemic comments
Olanzapine may alter glycaemia.
Bowel management comments
Regular intervention prescribed – no.
PRN interventions prescribed – no.
Nurse Initiated interventions administered – no.
Staff comments
Staff advise Ms ABY has been prescribed vitamin D since admission, and possibly before then. Advisable to clarify vitamin D levels and if still low then advisable to review the current management strategy.
Observations
Ms ABY is a small, pale, charming lady with a significant kyphosis, who told me she eats well and does not appear to be overweight.
Pharmaconutrition comments
Ferrous sulfate decreases zinc absorption therefore advisable to clarify zinc status and if low then consider a short term intervention.
Staff advise Ms ABY has been prescribed an iron intervention since admission, and possibly before then. Long term oral iron interventions are not recommended, therefore advisable to clarify iron status and if –
- within acceptable range then review necessity for its continued prescription,
- low then consider an alternate, non-oral intervention such as an iron infusion.
What else would you include?
Please read this as it is important …
The information in this article is provided to support Health Professionals. It is not an exhaustive protocol and Health Professionals are advised that adequate professional supervision is accessed to ensure that Duty of Care obligations with respect to safe administration of medicines is met for each consumer.
Yvonne Coleman has 30+ years of experience in aged care as a dietitian. Her mission is to make information about interactions between medicines and nutrition easy to access for those working in the healthcare sector. She has created a comprehensive resource identifying drug-nutrient and drug-food interactions from a nutrition perspective.
Her areas of competency include food science & nutrition, dietetics and health education. You can find out more about her work on LinkedIn, AusMed, the Enlightened Pharmacist podcast, and The FX Medicine Podcast.
