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| Photo credit:vegetable matter@blogspot.com |
If I had a dollar for
every time a patient told me (or I heard a doctor tell a patient) they "can't
eat greens or salads because I take Coumadin," well, let's just say, I
wouldn't have to keep this doctor thing up! What's the matter with this?
Well, it's not true. [For those of you wondering what Coumadin (generic
name, warfarin) is, a description follows.]
As a doctor who is
focused on helping people eat better, you can imagine how crazy this drives me.
And, more importantly, how negative an impact this has on the
health of millions of people.
Don't lose faith in
your trusty medical providers if you've been told this along the way.
Avoiding greens used to be the standard teaching. The thing about
medical science is that it's constantly evolving and advancing. As one of
my professors said early on in medical school, "half of what I'm telling
you will be proven wrong in the future - I just don't know which half."
What’s so special about greens?
Leafy greens are an
important part of a healthy diet. They're also an important part in
cultural traditions throughout the world. Greens add vitamin A, vitamin
C, fiber, calcium, iron, potassium, B vitamins, other minerals, omega-3 fatty
acids, many phytochemicals and phytonutrients - and the cause of concern
when it comes to Coumadin, but vitally important for health, vitamin K.
Vitamin K is necessary to keep bones strong, prevent heart disease and regulate bleeding and clotting.
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| Photo credit: www.wellbeingmag.com |
Before I get carried
away, I won’t assume everyone eats like a rabbit and knows what I mean when I
say “greens.” Greens are literally any
green vegetable or herb.
Some examples of greens
Examples of the
hundreds (maybe thousands) out there are: kale, spinach, chard, watercress and
other cress, lettuces, amaranth, celery, beet greens, turnip greens, collard
greens, mustard greens, dandelion, cabbage, Brussels sprouts, broccoli, bok
choy, rapini, endive, chicory, Jew’s mallow, Miner’s lettuce, cilantro, basil,
parsley, sage, arugula, spring mix and other mixed baby greens, fiddlehead
ferns, lovage, sorrel, sea kale, nori, chickweed, thyme, salsify, sea
vegetables…I could go on and on!
Exposing the myth
Why did the "I
can't eat greens" myth propagate so widely? It's because greens DO
interact with Coumadin. I know this is confusing - stick with me.
Coumadin is a blood
thinner – called an "anti-coagulant" in medical terminology. Millions of people
take it to prevent blood clots that can cause death or serious injury due to
stroke, blood clots in the lungs (called pulmonary emboli), leg pain and
swelling, among other things. People start taking it either temporarily,
or permanently, depending on the reason it was started in the first place.
Some reasons people start taking Coumadin are that they have irregular
heart rhythms, orthopedic surgeries (like hip replacement), artificial heart
valves, previous blood clots in the legs or lungs, problems with the blood or
diseases that cause increase risk of developing blood clots like lupus, factor
V Leiden, polycythemia vera, just to name a few. Cancers can also cause blood clots but are
treated with a different type of anti-coagulant.
How vitamin K interacts with Coumadin
Vitamin K, in
addition to the things mentioned above, is used to make components (called
"clotting factors") in the blood that help the blood to clot. These
clotting factors are made in the liver. When we eat foods or take daily
vitamins with vitamin K in them, we don’t just use up the vitamin K and get rid
of it. Our bodies recycle vitamin K!
Once vitamin K is used, it’s turned into an inactive (not useful) form of
vitamin K. For the liver to use the vitamin K again, it needs to be converted back to
an active (useful) form of vitamin K. Coumadin prevents the body from recycling inactive vitamin K to active vitamin K.
This basically makes most of the vitamin K in our bodies invisible or
useless.
The trick with Coumadin
is to block just the right amount of vitamin K – not too little and not too
much. This makes the blood less likely
than usual to clot, but not impossible. We
need some vitamin K active to make some clotting factors because if we weren’t
able to clot our blood at all, we would bleed to death. It's a delicate
balance. People born with diseases of the blood that make clotting
difficult, like hemophilia, live precariously with this problem. If
100 people took Coumadin for 1 year, 7 would have major bleeding and 1 person
would die from bleeding. It's very complicated to keep Coumadin at the right
level because many things besides vitamin K affect it. Regulating the level
often takes medical professionals who focus specifically on caring for patients
taking this medicine at a Coumadin clinic. Some doctors that have close
relationships with their patients and see them frequently, adjust the dose
themselves, but this is getting less common because of the amount of work
involved.
Interactions with Coumadin
Greens are just one
of the many, many things that interact with Coumadin – almost every medication
both prescription and over the counter, alcohol, grapefruit juice, cranberries,
multivitamins (especially vitamins A, C, E and K), some spices and seasonings (fenugreek,
anise, garlic, ginger, horseradish, licorice, turmeric), many herbal and
nutritional supplements, liver, natto (a Japanese food item), omega-3’s and
green tea just to name a few. As you can imagine, completely avoiding
everything that interacts is going to make life very tough to live! Many
of these things are difficult or impossible to give up.
How to live your life healthfully AND keep a safe Coumadin level
For things that would
have negative consequences for your health if given up - like greens, sources
of omega-3 fatty acids, losing weight, antibiotics and other lifesaving
treatments - don't give them up. Not giving them up means that you need
to work closely with your physician or Coumadin clinic to regulate your level. For
things that are in your normal daily routine, work with your providers to
stabilize your Coumadin level WHILE YOU CONTINUE TO use/eat them. Then, BE
AWARE WHEN CHANGES OCCUR to your routine and understand that some of those
changes will require close medical follow up to make sure that your Coumadin
level doesn't get too high or low.
Example 1, let's say
you eat a green salad three nights per week and have collard greens with your
Sunday meal. That's a lot of vitamin K, right? (It is, trust me on
this.) But remember, if this is your ROUTINE, let your doctors know and
they can adjust your Coumadin accordingly and get it to a stable level.
Then, you only need to be concerned about greens (or any other thing that
affects Coumadin levels) if you make a significant change.
Example 2 - Let's
say, it's a hot summer and you start eating large salads for one meal every
day. You've just doubled your intake of greens, and along with them
doubled your intake of vitamin K. You
will likely need a higher dose of Coumadin than you did before you made this
change.
Example 3 - Your
doctor gets the level adjusted and all is well until the fall. Suddenly, you
crave the warm comfort of soups and stews while the crisp, coolness of salads
seem less appealing. You cut out salads completely, but keep collards
with your Sunday meal. Well, now you are getting only about one-seventh
the amount of greens (and vitamin K) each week that you got in the summer.
You will definitely need a reduced Coumadin dose or risk life threatening
bleeding.
Example 4 - Similarly,
it you got pneumonia and had to take antibiotics, you would need your Coumadin
dose adjusted while on antibiotics.
Example 5 - If you hurt your shoulder and needed to take tylenol, again, adjustment would be needed.
For most of you
reading this who don't take Coumadin (and many who are), you're thinking,
"this is too complicated!" Well, it's true. Coumadin is one of
the most complicated medications you can take. No matter what your life
choices, your Coumadin level will likely need regular adjusting. Many,
many people are stuck with this archaic medication regimen. For some
lucky patients who meet very specific criteria, there are some substitute drugs
that are not nearly as difficult to regulate. Unfortunately, they're expensive
and they're not right for everyone.
Big Picture
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| Photo credit: www.healthwisehome.com |
Constant things don't
usually require big dose adjustments, changes to your lifestyle, foods and
medications/supplements often do. The key is
to create routines and stick with them. Notify your doctor or Coumadin
clinic of any changes to that routine. By doing this, you can maintain a
normal, healthy lifestyle - including eating a healthy diet rich in green
vegetables!
