Counseling the vaccine-hesitant patient
What’s at the root of most morbidity and mortality from influenza and other vaccine-preventable diseases? Under-immunization. Retail clinicians (i.e., nurse practioners, physician assistants and doctors) are in a unique position to influence immunization rates by educating patients on the benefits of appropriate vaccines. While myths surrounding vaccines — like the idea that the flu shot leads to contracting influenza and misguided information that vaccines lead to autism or mental retardation — have been dispelled by rigorous scientific investigation, people of all ages appear to be “skipping out” on vaccines.
With the current influenza season in full swing, retail clinicians should remain vigilant about offering the vaccine through March. Of those children who died of influenza last year, 90% had not received a flu vaccine. In contrast to previous flu seasons, the current flu strain has proven especially harmful to young adults who have not received the vaccine.
In counseling the vaccine-hesitant parent or patient, it is important to understand the basis for their stance against vaccines. Parental fears and concerns regarding vaccines often stem from misconceptions, including the belief that vaccine-preventable diseases no longer pose a risk, doubts about vaccine safety and beliefs that certain ingredients in vaccines are dangerous.
Vaccine-hesitant patients or parents can be categorized into five categories:
- Uninformed, but educable and seeks information to counter anti-vaccine information;
- Misinformed, but correctable and not fully aware of vaccine benefits;
- Well-read and open-minded, willing to discuss the issues with consideration of pros and cons;
- Strongly vaccine-resistant, willing to listen to both sides of the argument, but unlikely to change viewpoints soon; or
- Strong-willed and committed, attempts to convince provider to agree with the argument against vaccines. Parents in this last group are difficult to counsel.
Remembering that the goal is increased adherence (i.e., decreased morbidity and mortality from vaccine-preventable diseases), non-judgmental communication is the key to counseling around vaccines. As with any emotionally charged issue, clinician attitude can help or hinder shared decision-making. Vaccine Information Sheets, or VIS, given early in the exam can help parents or patients formulate questions. Clinicians should take time to solicit questions, acknowledging both benefits and risks. Respectful listening requires eye contact and refrains from patronizing behaviors. It is most important that clinicians not get offended, nor offend the patients, around issues of disagreement. Use of clear, simple language is of utmost importance.
With practice, clinicians can develop an attitude that is respectful of the parent or patient’s authority while encouraging vaccine adherence.
Hamacher Resource Group to hold workshop again in March
WAUKESHA, Wis. — Hamacher Resource Group has announced that is offering its workshop, How to Grow Sales Within Independent Pharmacy, again on March 6 at its headquarters in Waukesha, Wis.
The one-day session is open to health, beauty and wellness manufacturers that are looking for in-depth information about how to navigate the channel. Dave Wendland, HRG VP and member of the owners group, will lead the workshop and provide insights and advice based on his 20-plus years of experience in the industry and long-standing relationships with HBW manufacturers, wholesalers, and independent pharmacies.
How to Grow Sales Within Independent Pharmacy covers the best practices for suppliers who want to expand distribution and sales in the independent pharmacy channel. The Jan. 23 workshop sold out before the early bird deadline, and the March workshop was added based on the high amount of interest.
“HRG’s bird’s-eye view of the HBW industry and relationships with each segment of the supply chain bring a deep and broad perspective to the wisdom we can share about how to succeed with independent pharmacies,” Wendland stated.
Space for the workshop is limited and the registration deadline is Feb. 21. An early bird discount is available through Feb. 7. Those interested can learn more at Hamacher.com/IndieWorkshop, by calling (800) 888-0889, or by emailing the workshop registrar at [email protected]
Chain reaction: Addressing patients’ nutrition deficiencies
Americans by and large have lousy diets, pharmacist and supplement expert James LaValle, CEO of Integrative Health Resources, told DSN Collaborative Care recently. Over a lifetime, those nutrient-poor diets contribute to the development of such chronic disease states as obesity, hypertension and diabetes. The medicines prescribed to treat those conditions then further deplete essential vitamins and minerals.
“Because of the poor nutrition status of people … there’s a lot more irritable bowel disease, colitis and hyperthyroidism. There’s a lot of conditions that relate to your ability to absorb nutrients from your food,” he said. “And when you combine that with food that isn’t as nutrient-dense, and then you combine that with medications that are depleting nutrients, it creates somewhat of a chain reaction, or momentum, that accelerates people toward [poor health] issues.”
For example, magnesium plays a role in maintaining healthy blood-sugar levels and is the most-identified nutrient depletion with the development of Type 2 diabetes and metabolic syndrome. “Culturally, we don’t get a lot of magnesium in our diet,” LaValle said. “And then if I put you on a medication that depletes magnesium, it exasperates the situation.”
It’s a vicious cycle. But it’s a cycle to which more practitioners are becoming sensitive. “With the advent of people studying nutrigenomics, what we’re seeing is that interface between a drug that depletes a nutrient and someone who’s genetically predisposed toward the depletion of that nutrient,” LaValle said. “That can accelerate the potential side effects that can occur from the drug.”
Some of the more significant medications causing nutrient depletion are oral contraceptives, which cause vitamin B-6 deficiency that triggers bouts of depression. The study of nutrigenomics has revealed that vitamin B-6 deficiency inhibits the methylation of serotonin and results in feelings of depression.
That’s just one example of how a nutrient depletion can contribute to the side effects associated with a particular medicine, which in turn could impact adherence to a medicine regimen if the side effect is too jarring to the patient. Paying attention to which medicines deplete which nutrients, and thereby avoiding some of these side effects, could improve medication adherence, LaValle suggested.
Having a firm grasp of the importance of nutrient depletion is key for another reason: Many of those Americans who have poor lifestyle choices are enabled by medicines. So knowing what nutrients are important for specific disease states and medicine regimens can help turn the tide in getting those patients off those medicines because they no longer need them.
For example, men on statins are twice as likely to have low testosterone. Low testosterone has been linked to a higher risk of cardiovascular disease. To make testosterone, men need magnesium and zinc. However, to help control high blood pressure, physicians may prescribe a thiazide, which depletes magnesium and zinc. So a physician prescribing a statin and thiazide can in fact lead to increased cardiovascular risk for the patient if underlying nutrient depletions are not addressed in conjunction with the drug therapy.
There’s a curriculum trend in support of teaching the consequences of nutrient depletion and poor lifestyle choices at medical schools, LaValle noted. LaValle is the course director of George Washington University’s new Integrative and Metabolic Medicine program, a 270-hour course for physicians learning about exercise, lifestyle, stress response and nutrition. “All those aspects are not taught in school [currently],” LaValle said. “And there are other programs like that that are beginning to percolate everywhere in academia that are more oriented toward teaching physicians lifestyle, behavior, nutrition and prevention. Truly emphasizing to [medical students] the value of the type of diets that they put their patients on, the value in trying to get the patient to manage their health better so that the medications can be limited.”
Beyond lifestyle choices and prescription regimens, certain demographics may influence nutrient depletion. Members of high-income households (i.e., more than $75,000) are less likely to have nutrient shortfalls than households with less income. Obesity also raises the risk of nutrient depletion. Patients with a normal BMI typically have inadequate intake of calcium and vitamins A and C, but those who are overweight and obese also struggle with magnesium, and vitamins D and E.
A large percentage of older Americans have inadequate intakes of vitamins A, C, D and E; calcium; and magnesium, according to the National Health and Nutrition Examination Survey.
Of particular note, practically all older Americans are not meeting the recommended intake for vitamins D and E. These nutrients have important roles in bone and heart health, and in providing antioxidant support. And older Americans tend to consume fewer calories due to a decreased appetite, posing a challenge to correcting nutrient shortfalls through a food-only approach.
That makes it important to know which medicines deplete which nutrients, LaValle said, no matter what age you are.