There’s no tougher time for dieting than the holidays. Whether you’ve got serious health restrictions or just trying to lose a couple of extraneous pounds, it’s difficult to maintain one’s sense of discipline when a big, fat turkey dinner is just lounging on the table, waiting for you, singing to you its siren song. “You know you want me,” it whispers seductively — and you do, you really, really do.
Anticoagulation therapy patients are lucky in that ours is a relatively lenient diet. A friend of mine, for instance, was diagnosed in her early 20s with Crohn’s disease, a chronic inflammatory bowel disease which put some strict restrictions on her eating habits. Certain foods, including corn, wheat, and carbonated drinks, can make her very ill, so she uses a modified paleo diet as a guide to help her keep tabs on what she can and can’t eat.
Just because ACT patients don’t have it quite so rough, however, doesn’t mean maintaining a healthy INR diet is always a walk in the park. Watching those Vitamin K levels can become a chore, particularly if you’re a fan of salads, kale, or other leafy green vegetables. And then, of course, there’s the festivity factor: a myriad of elements which come into play during the holidays — including overeating, stress, and exercise (or a lack thereof) — can also impact the effectiveness of anticoagulant medications.
With that in mind, now seems like the perfect time to share what I’ve learned so far with regards to sticking to a diet — specifically, an INR diet. These tips, of course, are handy in any season, but should be especially helpful to refer to during the festive months ahead, when food temptation tends to be at its worst.
Keep a food diary.
The best way to keep track of anything is to take organized notes. When I first came home from the hospital following my AVR surgery, I realized that getting used to my new food restrictions would be a long process. So I printed out some charts of foods both high in Vitamin K, bookmarked the USDA searchable nutrient database, and began to get in the habit of noting down whatever I ate each day. I spent a few days working out about how much Vitamin K I would need to allow myself per day in order to be satisfied (I do enjoy my salads). Once I had a basic range to work with, the real work began — staying in that range.
If you’re just beginning your ACT journey, don’t be discouraged: it gets easier. In recent weeks my INR has finally begun to stabilize in the proper range, and after all the practice I’ve had measuring foods and memorizing (by dint of looking it up so many times) the Vitamin K levels of certain staples in my diet, I’ve gotten to the point where I don’t really need my food diary as much. But if you’re fresh out of the hospital, have memory issues, or find your INR continually fluctuating out of range, I would definitely recommend keeping a food diary of some sort, at least for awhile.
As an example, below are a couple of download links for the template I use for my own INR management. Feel free to use it or share it as you will — but please link back to this post if you do!
Some items are not food-related — this is because some factors besides diet can affect some patients’ INR levels. I kept tabs on these for awhile to make sure I wasn’t one such patient. (I do believe stress affects mine, albeit minimally.) Also, you’ll notice I don’t have a simple “date” field at the top of the form. Instead, I measure my Vitamin K intake by “time period.” This is because I no longer measure my Vitamin K intake by day, but rather by what I eat between each Coumadin dose. Each entry, therefore, is dated in the following format: Nov 4, 6PM – Nov 5, 6PM. Measuring this way helps me keep my levels extra stable without forcing me to restrict my Vitamin K intake to a particular time of day (i.e. always having my greens at lunch, but never at breakfast or dinner).
Remember: leafy greens aren’t the only foods that interact with blood thinners.
One important thing to remember about INR management is that leafy greens aren’t the only foods which contain Vitamin K. Though it’s true they are by far the biggest and most common of the culprits, you might be surprised at some of the other foods which, though not green, can still knock your INR off-track if you’re not careful.
Some common (non-green) foods to watch out for:
- Mayonnaise: While not necessarily high in K content (the USDA lists regular mayo as containing around 30 mcg per tablespoon), the amount of vegetable oil — and thus, Vitamin K — can vary wildly between brands, types, and batches of mayo, making it extremely difficult to figure just how much K you’re really getting when you eat it. One solution is to make your own — according to the Coumadin Cookbook, exposing the necessary oil ingredient to sunlight or UV light can “kill” most of the vitamin K content. Or just don’t eat it often.
- Pie Crust: Who’d’ve thunk it? Again, this one’s a big variable — K content seems to fall anywhere between 10 and 20 mcg — and while I definitely wouldn’t tell anyone to outright avoid such a holiday favorite, it’s still something to keep in mind if you also plan on partaking of some boiled cabbage or steamed broccoli on the same day.
- French Fries: Thanks to the vegetable oil they’re usually cooked in, a large serving of fast food fries usually falls around 17 mcg — except when it doesn’t. Five Guys Burgers and Fries, for example, fry their foods in peanut oil, which is extremely low in Vitamin K. (Their fries, like most fast food, are high in calories of course, but darned if they’re not also ridiculously delicious.) Again, these don’t need to be avoided, just eaten in moderation.
- Cranberries: With these it’s not the vitamin K content, but the salicylic acid. While small amounts of cranberries and cranberry juice should be all right (provided you don’t consume them regularly), higher consumption of cranberry products can interact with blood thinners and cause bleeding problems.
- Grapefruit: Like cranberries, the problem here isn’t Vitamin K content, it’s drug interactions. Grapefruit, for whatever reason, interacts badly with a lot of prescription medication — including blood thinners (and metoprolol, for that matter). While tiny amounts may not matter much in the long run, this one is generally best avoided.
Be your own chef.
The easiest way to keep track of what you eat is to make it yourself. This way, even if a given recipe contains Vitamin K, you at least know approximately how much is in it — which is a lot easier than guessing how much is in your friend’s favorite guacamole recipe at a party, or how many cups of romaine are in your favorite Olive Garden salad. (Bonus: eating in usually saves you money as well as calories if you do it right.) If you actually enjoy cooking, so much the better!
This applies to parties as well. Any time you have the opportunity to contribute food to an event you’re going to be at, be it a party or a BBQ or a potluck dinner, offer to bring a dish you love and can eat without reservations — in other words, something low in Vitamin K and at least decently nutritious. This way, you’ll have at least one food at the party (besides dessert) that you know is safe for your diet and that you actually enjoy. My go-to recipes are usually either ham and cheese pinwheels (even better with whole-wheat dough) or some sort of K-friendly fruit salad.
Another great thing about cooking your own food is the opportunity to use substitutions which might not be available in restaurants or a relatives’ pantry. For instance, if you have a craving for fast food fries but already ate your Vitamin K for the day, you could easily bake yourself some delicious — not to mention fresh — fries, which would be both healthier and much lower in K content! Another example is this awesome skinny crustless apple pie recipe I stumbled across recently — lots of flavor, no K, and so easy to make! If you really crave the crunch of the crust, though, I imagine tossing in some oatmeal cookies (the harder variety, not the soft-baked ones!) or something like that could easily serve as a tasty substitute.
Stock your fridge.
Going hand-in-hand with the DIY suggestion, the idea here is that if you make sure you are surrounded by the right foods, you will eat the right foods. Keep healthy foods, like whole grains and fresh fruits and veggies, on hand and stay away from heavily processed junk food and sweets. For most heart patients, a low-sodium, blood pressure friendly diet is ideal — although in my case, my perpetually low blood pressure actually means I keep naturally salty foods and low-sugar sports drinks around for times when it dips a little too low.
Similarly, ACT patients should make sure to always have a quick source of Vitamin K stocked — skipping out on K completely, particularly when you normally have a fair amount, can just as bad as eating too much of it, since it keeps your INR from going too high (which can lead to bleeding problems). I’ve gotten in the habit of keeping romaine and raw broccoli in the fridge at all times. They’re cheap, there’s no prep needed, and they can be consumed quickly if I suddenly realize it’s almost time for my next Coumadin dose and I haven’t met my K quota yet.
I also keep small, healthy snacks like fiber bars in my purse for the other medications I take which need to be taken with food. This way, when I go out I won’t be stuck grabbing some uber-sugary candy from a vending machine just to be able to take my pills on time.
Acquaint yourself with proper portions.
Before surgery, I never had diet restrictions and had only just barely begun to cook for myself — thus, I wasn’t very good with guessing portion sizes. In general, the best way to guess at a healthy portion (without measuring every little thing, which gets tedious fast) is by remembering some key size comparisons. For me, the best study guides come in the form of infographics — like this one from Guard Your Health, or this one from the American Heart Association.
When it comes to basic healthy portion sizes, as Captain Barbossa would say, they’re “more what you’d call guidelines than actual rules.” Vitamin K measurements, however, are a little bit trickier. There’s no one-size-fits-all infographic that can tell all ACT patients about how much K they need, because it’s up to patients to set their own ranges and then stick to them. If Step One is figuring out how much K you want in your life, then Step Two is getting used to eating just about that amount every single day.
Here’s the thing: I suck at eyeballing measurements. That is why, most of the time, I take a minute to actually measure out what I’m eating. When I make salad, I make sure it has two cups of romaine (unless other green ingredients are involved, in which case I adjust the amount accordingly). When I’m in the mood for raw veggies, I double check that I’m not eating more than my usual maximum daily serving of broccoli, which I’ve determined is one cup. Sure, it can be annoying sometimes, but for me, the benefit of knowing my measurements are accurate (and therefore won’t cause a big swing in my INR) outweighs the minor cost of a few extra seconds of meal prep. With time and lots of practice, I’ve slowly gotten better at guessing thanks to seeing what these measurements actually look like over and over again. Now, even when I’m dining out or at a friend’s house, I can guess with decent accuracy at my personal proper K portion sizes without randomly whipping out a set of measuring cups in the middle of the meal.
While it’s important to keep track of what you eat and to try your best to stay in your ideal INR range, it’s important to also remember that your body is a living, breathing organism, not a machine. Your INR will always fluctuate a little due to natural, constant changes in your body, and it’s pretty much impossible to actually know exactly how much Vitamin K you’re consuming on a daily basis. I know all too well how easy it is to fall into the trap of thinking you can actually achieve total control over your your INR, your body, your life. The hard fact is, however, that such control is an illusion, and desperately striving for it is no more effective than chasing the mirage of an oasis in the desert, and can be just as depressing.
So do yourself a favor and chill. Do your homework, put in the time and effort necessary to form some good habits (and let go of some bad ones) and keep track of things — and then drop it. Don’t stress yourself out worrying about every bite you take, and don’t freak out when, occasionally, your INR falls slightly out of range.
On the same token, don’t be hard on yourself if you do have a hard time with it, particularly if you’ve only just started anticoagulation therapy. It takes time for your body to stabilize and for you and your doctors to find a dose that’s right for you, and it takes time to adjust to any lifestyle change. It’s okay to worry, to feel frustrated, to feel down — just don’t let it keep you down. While it’s important to do your best, don’t forget that you are allowed the occasional treat. So take a bite of that apple pie, drizzle a bit of your aunt’s famous cranberry sauce on that turkey, and enjoy your holidays!
Know any good INR management hints or tips for sticking to a diet through the holidays? How about a favorite low K-content recipe you’re dying to share? Post them below in the comments!