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Diuretics and Diets
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Diuretics are a group of drugs given to help the body eliminate excess fluid
through the kidneys in order to treat hypertension (high blood pressure),
kidney and liver disorders, glaucoma, congestive heart failure (CHF), and
idiopathic intracranial hypertension (pseudotumor cerebri), a condition
characterized by increased fluid pressure within the blood vessels
supplying the brain.
In addition to prescription diuretics, there are several types of diuretics
available in over-the-counter formulations or commonplace beverages.
Purpose
Diuretics have several purposes in mainstream clinical medicine:
To lower blood pressure in people with hypertension
To lower fluid pressure inside the eyeball in patients with glaucoma
To reduce increased cerebrospinal fluid pressure in idiopathic
intracranial hypertension
To reduce blood pressure and swelling during surgical procedures
To reduce bloating and discomfort associated with fluid retention in
the premenstrual phase of a woman’s monthly cycle
The connection between diuretics and
dieting is twofold. First, many of the
conditions that are treated by
administration of prescription diuretics—
particularly hypertension, CHF, and
idiopathic intracranial hypertension—are
more common in obese patients, more
difficult to treat in the obese population,
or both. Thus weight loss and lifestyle
change are commonly recommended to
these patients along with prescription
diuretics.
The second connection is that many
dieters use or abuse diuretics as a means
KEY TERMS
Caffeine—A plant alkaloid
found in coffee, tea, hot
chocolate, and some soft
drinks that functions as a
diuretic as well as a central
nervous system stimulant.
Edema—Abnormal and
excessive accumulation of
fluid in body tissues or certain
cavities of the body. Edema is
ADVERTISEMENT
to quick weight loss. Abuse of diuretics
frequently coexists with self-induced
vomiting and abuse of laxatives in
patients with eating disorders This
combination of behaviors is called
purging. Purging may occur in some
patients with eating disorders as a means
to a slender appearance, but it is also
common in high school and college
athletes participating in such weightrelated sports as rowing, wrestling,
gymnastics, and long-distance running.
Athletes may also abuse diuretics like
furose-mide (Lasix) in order to mask the
fact that they are taking other drugs to
enhance performance in competition.
People who abuse diuretics may take
herbal preparations reported to have
diuretic effects or over-the-counter
preparations containing caffeine or
pamabrom as well as prescription
diuretics.
Description
Prescription diuretics
There are five major types of prescription
diuretics.
LOOP DIURETICS Loop diuretics are the
strongest of the prescription diuretics.
They take their name from the fact that
they work in the ascending limb of the
loop of Henle, a structure in the kidney in
which magnesium and calcium are
ordinarily reabsorbed. By disrupting the
reabsorption of these two ions, loop
diuretics bring about increased urine
production, which in turn lowers blood
volume, leading to lowered blood
pressure. Loop diuretics also cause the
veins to dilate, which lowers blood
pressure mechanically. This vasodilation
is independent of the drug’s diuretic
effect.
THIAZIDE DIURETICS Thiazide
diuretics are derived from a chemical
called benzothiadi(A)zene. Unlike the
loop diuretics, which work in the loop of
Henle, thiazide diuretics work in a
different structure called the distal
convoluted tubule, although they function
in a similar way to increase urine
production by decreasing the kidney’s
reabsorption of sodium and calcium.
They are not as strong as loop diuretics
and have fewer adverse effects.
a symptom of a number of
different kidney, liver, and
circulatory disorders and is
commonly treated with
diuretics.
Electrolyte—Any of several
chemicals dissolved in blood
and other body fluids that are
capable of conducting an
electric current. The most
important electrolytes in
humans and other animals are
sodium, potassium, calcium,
magnesium, chloride,
phosphate, and hydrogen
carbonate.
Ethanol—The chemical name
of beverage alcohol.
Glaucoma—An eye disorder
marked by increased fluid
pressure within the eyeball
that can lead to gradual loss
of vision. Glaucoma is
sometimes treated with
diuretics.
Hypercalcemia—Abnormally
high levels of calcium in the
blood.
Hypertension—The medical
name for high blood pressure.
Idiopathic intracranial
hypertension—Increased
fluid pressure within the blood
vessels supplying the brain.
Obese women are at
increased risk of developing
this disorder.
Nephrotic syndrome—A
disorder marked by a
deficiency of albumin (a
protein) in the blood and its
excretion in the urine.
Ototoxicity—Damage caused
to the nerves in the ear that
are involved in hearing or
balance. Ototoxicity is a rare
but serious adverse affect of
loop diuretics.
Pamabrom—A mild diuretic
found in several over-thecounter compounds for the
relief of premenstrual
discomfort and water
retention.
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Thiazide diuretics are commonly
prescribed to manage high blood
pressure because they help to dilate
blood vessels as well as lower blood
volume by increasing urine output. They
are also sometimes given to patients with
high levels of calcium in the urine to
prevent the formation of kidney stones
and lower the risk of osteoporosis They
include such drugs as hydrochlorothiazide
(HydroDiuril, Esidrix), chlorothiazide
(Diachlor, Diuril), and chlorthalidone
(Hygroton, Hylidone).
Purging—A behavior
associated with eating
disorders that includes selfinduced vomiting and abuse
of laxatives as well as
diuretics.
Theobromine—A breakdown
product of caffeine that is
responsible for the diuretic
effect of coffee and tea.
POTASSIUM-SPARING DIURETICS Potassium-sparing diuretics include
such drugs as amiloride (Midamor) and triamterene (Dyrenium). They are
usually given together with loop diuretics in treating CHF or high blood
pressure to prevent the patient’s potassium level from falling too low. They
work by decreasing sodium reabsorption in the collecting tubules of the
kidneys.
There are two formulations that combine the potassium-sparing diuretic
triamterene with the thiazide diuretic hydrochlorothiazide in one pill—
Maxzide and Dyazide—thus simplifying the patient’s dosage schedule.
OSMOTIC DIURETICS Osmotic diuretics are substances that cannot be
reabsorbed in the kidney and so increase urine volume by osmosis. The
most commonly used osmotic diuretic is mannitol, a sugar alcohol or
polyol that is also added to sugar-free candies, mouthwashes, and similar
products as an artificial sweetener. Mannitol (Osmitrol) is given
intravenously to patients with glaucoma to lower fluid pressure inside they
eyeball, and to patients with acute kidney failure following cardiovascular
surgery.
Until early 2007, high-dose mannitol was recommended as treatment to
reduce fluid accumulation inside the skull in cases of head trauma, on the
basis of randomized trials conducted by a neurosurgeon in Brazil who
committed suicide in 2005. His papers on the use of mannitol in head
surgery were called into question in late 2006; neither his former
coauthors nor the journal editors who published his studies have been able
to verify his data; and the university he claimed as his affiliation has never
employed him.
CARBONIC ANHYDRASE INHIBITORS Carbonic anhy-drase inhibitors
are a class of diuretics that increase water loss through the kidneys by
changing the acidity of urine. Their most common use, however, is to treat
glaucoma by lowering the fluid pressure inside the eyeball. The most
common diuretic in this group, acetazolamide (Diamox), is also used as an
anticon-vulsant (drug given to prevent seizures). Other carbonic
anhydrase inhibitors include dichlorphenamide (Daranide) and
methazolamide (Neptazane).
Nonprescription diuretics
Nonprescription diuretics are often used by dieters to flush water from the
body in the belief that this practice will promote rapid weight loss.
According to the Centers for Disease Control and Prevention (CDC), 1% of
adult male dieters in the United States and 2% of adult women have used
over-the-counter diuretics as part of weight loss attempts.
CAFFEINE Caffeine is a xanthine alkaloid found naturally in coffee beans,
tea leaves, kola nuts, cocoa beans, and a few other plants. It is well
known as a central nervous system (CNS) stimulant, enjoyed in brewed
coffee, tea, hot chocolate, cola beverages, and energy drinks. It is also
available in tablet form as an over-the-counter stimulant in such
compounds as NoDoz. Caffeine is broken down in the liver to three
substances, one of which is theobromine, which acts as a diuretic and
increases urine volume. Some dieters drink coffee as much for its diuretic
effects as for its effectiveness is counteracting the fatigue that often
accompanies low-calorie diets.
HERBAL PREPARATIONS Naturopaths and other practitioners of
alternative medicine often recommend certain herbal preparations,
including herbal teas, as diuretics available without a prescription. Herbs
commonly recommended for their diuretic qualities include uva ursi,
dandelion, hydrangea, parsley, butcher’s broom, buchu, juniper, horsetail,
buckthorn, and asparagus.
PAMABROM Pamabrom is a mild diuretic related chemically to
theophylline, one of the breakdown products of caffeine. It is compounded
with acetaminophen in a number of over-the-counter (OTC) remedies for
premenstrual bloating and backache associated with fluid retention,
including New Tylenol for Women, Backaid, and Diurex.
Precautions
Both prescription and nonprescription diuretics should be used with care.
Prescription diuretics
Prescription diuretics should be used only under a doctor’s supervision and
monitored in long-term users, as dosage requirements may change or the
doctor may recommend dietary supplements to compensate for
electrolytes and nutrients lost through the use of some diuretics. In
addition, patients should not stop taking prescription diuretics or change
the dosage without consulting their doctor.
Loop diuretics. Patients taking loop diuretics may require
supplemental potassium, folic acid, and vitamin B1. In addition, they
should learn to recognize the symptoms of potassium depletion, as
loss of potassium is a common adverse effect of this type of diuretic
Thiazide diuretics. Nursing mothers should not use thiazide diuretics
during the first month of breastfeeding, as they can pass into the
milk and in some cases decrease the flow of milk. Thiazide diuretics
should also be taken with food or milk to lower the risk of upset
stomach. They should be used very cautiously in patients with
diabetes, as they tend to raise blood sugar levels
Potassium-sparing diuretics. Patients should avoid the use of salt
substitutes containing potassium while taking this type of diuretic,
as it may lead to overly high levels of potassium in the blood. In
addition, patients should be advised to avoid driving or operating
dangerous machinery until they know how these drugs affect them,
because potassium-sparing diuretics may cause dizziness and
blurred vision
Osmotic diuretics. Sodium levels in the patient’s blood should be
closely monitored, particularly if the patient develops muscle
cramps
Carbonic anhydrase inhibitors. Acetazolamide should not be given to
patients with a history of liver or kidney disorders, Addison’s
disease, known sensitivity to sulfonamide drugs, or angle-closure
glaucoma; and used cautiously in patients with diabetes or gout.
The patient should be advised to take this type of diuretic in the
morning to prevent sleep interruption
Nonprescription diuretics
Nonprescription diuretics can still cause adverse effects even though they
are weaker than prescription diuretics:
Caffeine. A dose of caffeine higher than 400 milligrams (more than
3 or 4 cups of brewed coffee) will produce a state of caffeine
intoxication in most adults. Over-the-counter caffeine tablets,
however, typically contain more caffeine than brewed coffee, usually
100-200 mg per tablet. In very high doses (around 5 g), caffeine
will produce nausea, coma, convulsions, and eventually death
Herbal preparations. Herbal preparations should be purchased only
from reliable sources, as their potency may vary from batch to
batch. In addition, herbal products made outside the United States
may be adulterated with filler products or contaminated by
industrial byproducts
Alcohol. Alcohol should always be consumed in moderation and
never combined with driving or operating heavy machinery
Pamabrom. Pamabrom is a mild diuretic that causes skin rashes in a
few people who take it for backache or menstrual cramps
Interactions
Prescription diuretics interact with some other prescription drugs as well as
with herbal products:
Loop diuretics. Loop diuretics are known to interact with licorice,
digitalis, and buckthorn or alder buckthorn
Thiazide diuretics. Thiazide diuretics interact with insulin to inhibit
its effects in lowering blood sugar; they intensify the toxic side
effects of lithium therapy; and they increase the effects of
corticosteroids in causing loss of potassium
Potassium-sparing diuretics. May increase the toxicity of lithium
Osmotic diuretics. None reported as of 2007
Nonprescription diuretics
Nonprescription diuretics, particularly alcohol, may interact with a variety
of substances:
Caffeine. Caffeine is known to intensify the effects of cimetidine (a
drug that lowers the secretion of stomach acid) and theophylline
Herbal preparations. Herbal preparations with diuretic effects should
be strictly avoided by people taking prescription diuretics, as the
herbs may intensify the effects of the prescription drugs and lead to
various cardiovascular side effects
Alcohol. Alcohol is known to interact with a wide number of
prescription medications. It should never be taken together with
other drugs that depress the central nervous system. These types of
medications include antidepressants, benzodiazepines
(tranquilizers), barbiturates, other sleeping medications, narcotic
pain relievers (codeine and other derivatives of opium), and
antihistamines. Alcohol may interact with antipsychotic medications
to cause liver damage, with aspirin to cause stomach bleeding, and
with some cardiovascular medications to cause dizziness and
fainting
Pamabrom. No interactions between pamabrom and other
medications have been reported as of 2007
Aftercare
Aftercare following abuse of diuretics varies according to the substance
and the consumption pattern. Caffeine intoxication can usually be treated
by tapering intake of caffeinated beverages and/or discontinuing use of
caffeine tablets. Alcohol hangovers may require rehydration as well as
administration of vitamin B6 Abuse of diuretics in patients with eating
disorders requires long-term medical nutrition therapy supervised by a
professional nutritionist. The position statement of the American Dietetic
Association (ADA) is as follows: “It is the position of the American Dietetic
Association (ADA) that nutrition education and nutrition intervention by a
registered dietitian is an essential component of the team treatment of
patients with anorexia nervosa, bulimia nervosa, and eating disorders
not otherwise specified (EDNOS) during assessment and treatment across
the continuum of care.’ Similarly, adolescents who abuse diuretics as part
of athletic training regimens require supervision by a registered dietitian
as well as by a specialist in sports medicine.
Complications
Prescription diuretics have a number of side effects:
Loop diuretics. Loop diuretics may produce several different types of
adverse reactions. The first type are related to diuresis and
electrolyte balance. Loop diuretics may cause loss of potassium and
magnesium from the body; the loss of magnesium may lead to the
loss of additional potassium. Patients taking loop diuretics should be
taught to recognize the signs of potassium deficiency
(hypokalemia), which include weakness, loss of appetite, irregular
heartbeat, constipation, muscle cramps, a weak or heavy feeling in
the legs, mental confusion, or unusual tiredness. The second type of
adverse reaction to loop diuretics is ototoxicity, or damage to the
nerves in the ears that control hearing and the sense of balance.
Symptoms of ototoxicity include ringing in the ears (tinnitus) and
dizziness. The third type of adverse effect of loop diuretics is
uncommon but may occur in patients who are also taking ACE
inhibitors (medications to control blood pressure) and nonsteroidal
antiinflammatory drugs (NSAIDs). This so-called “triple whammy’
may lead to kidney failure
Thiazide diuretics. Thiazide diuretics may cause low blood potassium
levels, impotence in men, and increased levels of blood cholesterol.
They also cause photosensitivity in some people, which means that
the person will be more sensitive to sunlight and sunburn more
readily. Last, thiazide diuretics can raise the levels of glucose and
uric acid in the blood, which increases the patient’s risk of
developing gout
Potassium-sparing diuretics. Adverse effects may include loss of
interest in sex (in both men and women), visual disturbances and
dizziness, shortness of breath, nausea and vomiting
Osmotic diuretics. Use of mannitol causes high blood pressure,
blurred vision, chills, fever, nausea, and vomiting in some patients
Carbonic anhydrase inhibitors. May depress the activity of bone
marrow, leading to anemia; may contribute to liver dysfunction;
increases the patient’s risk of developing gut; may lead to overly
low blood levels of sodium, potassium, magnesium, and calcium
Nonprescription diuretics
Adverse effects from nonprescription diuretics may include:
Herbal preparations. Herbal preparations used as diuretics have a
wide range of potential adverse effects, ranging from intensifying
the effects of prescription diuretics to indigestion, skin rashes,
headache, and diarrhea
Alcohol. Complications associated with ethanol consumption include
the risks of dehydration and electrolyte imbalance caused by
intoxication; alcohol abuse; trauma from alcohol-related accidents;
and interactions with other medications
Pamabrom. Pamabrom has been reported to cause skin rashes and
dependence in a very small minority of patients
Parental concerns
Parents do not ordinarily need to be concerned about children or
adolescents abusing prescription diuretics, as these drugs do not produce
mood alteration or relieve pain. Adolescents, however, are likely to abuse
nonprescription diuretics in relation to eating disorders or athletic
competition; one study found that 64% of adolescents diagnosed with
eating disorders were using herbal diuretics. A few adolescents may
develop caffeine-related disorders apart from eating disorders or sports.
Eating disorders
Abuse of over-the-counter diuretics is common among adolescents with
eating disorders accompanied by purging, although it is slightly less
common than self-induced vomiting or abuse of laxatives. Although eating
disorders are classified as mental health problems, they can have serious
lifelong digestive and nutritional consequences, including erosion of tooth
enamel, loss of bone density leading to eventual osteoporosis, and ongoing
problems with water retention.
Athletic competition
Numerous reports of diuretic abuse among athletes in high school and
college sports programs have accumulated since the late 1980s. Abuse of
OTC diuretics is higher among both males and females in such weightrelated sports as wrestling and rowing than among participants in sports
that do not classify athletes by weight (distance running, swimming,
basketball, etc.). More males than females abuse diuretics at both the high
school and college levels; the average age of initial misuse of diuretics in
one sample was 15.6 years for males and 16.2 years for females. Abuse of
diuretics puts young athletes, particularly males, at risk of dehydration,
chest pains, fainting, and irregular heart rhythms, particularly when
combined with ephe-drine or other stimulants.
Caffeine dependence and intoxication
According to DSM-IV, caffeine use typically begins in the mid-teens in the
United States and Canada, with levels of consumption increasing into the
early adult years (20s and 30s). Among teenagers, caffeine use is usually
higher among boys than girls, and higher among smokers than
nonsmokers. Most fatal cases of caffeine overdose occur among adults in
their early 20s, usually as a result of taking OTC caffeine tablets by mouth
or inhaling crushed tablets.
Resources top
BOOKS
American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders, fourth edition, text revision. Washington, DC: American
Psychiatric Association, 2000.
American Society of Health-System Pharmacists (ASHP). AHFS Drug
Handbook, 2nd ed. Philadelphia: Lippin-cott Williams & Wilkins, 2003.
Nurses Drug Guide Nowalk, CT: Appleton & Lange, 2000.
Pelletier, Kenneth R., MD. The Best Alternative Medicine, Chapter 6,
“Western Herbal Medicine.’ New York: Fireside Books, 2002.
PERIODICALS
American Dietetic Association (ADA). “Position of the American Dietetic
Association: Nutrition Intervention in the Treatment of Anorexia Nervosa,
Bulimia Nervosa, and Other Eating Disorders.’ Journal of the American
Dietetic Association 106 (December 2006): 2073–2082.
Gans, Mark, MD. “Idiopathic Intracranial Hypertension.’ eMedicine, July 25,
2006. Available online at http://www.emedicine.com/oph/topic190.htm
(accessed April 13, 2007).
Hoyng, P. F., and L. M. van Beek. “Pharmacological Therapy for Glaucoma:
A Review.’ Drugs 59 (March 2000): 411–434.
Karlson, K. A., C. B. Becker, and A. Merkur. “Prevalence of Eating
Disordered Behavior in Collegiate Lightweight Women Rowers and Distance
Runners.’ Clinical Journal of Sport Medicine 11 (January 2001): 32–37.
Kerrigan, Sarah, and Tania Lindsey. “Fatal Caffeine Overdose: Two Case
Reports.’ Forensic Science International 153 (October 4, 2005): 67–69.
Kiningham, R.B., and D. W. Gorenflo. “Weight Loss Methods of High School
Wrestlers.’ Medicine and Science in Sports and Exercise 33 (May 2001):
810–813.
Kruger, J., D. A. Galuska, M. K. Serdula, and D. A. Jones. “Attempting to
Lose Weight: Specific Practices among U.S. Adults.’ American Journal of
Preventive Medicine 26 (June 2004): 402–406.
Myers, J. B., K. M. Guskiewicz, and B. L. Riemann. “Syncope and Atypical
Chest Pain in an Intercollegiate Wrestler: A Case Report.’ Journal of
Athletic Training 34 (July 1999): 263–266.
Orbeta, R. L., M. D. Overpeck, D. Ramcharran, et al. “High Caffeine Intake
in Adolescents.’ Journal of Adolescent Health 38 (April 2006): 451–453.
Roberts, Ian, Richard Smith, and Stephen Evans. “Doubts over Head
Injury Studies.’ BMJ 334 (February 24, 2007): 392–394.
Roerig, James L., James E. Mitchell, M. de Zwaan, et al. “The Eating
Disorders Medicine Cabinet Revisited: A Clinician’s Guide to Appetite
Suppressants and Diuretics.’ International Journal of Eating Disorders 33
(May 2003): 443–457.
Steffen, Kristine J., James L. Roerig, James E. Mitchell, and Ross D.
Crosby. “A Survey of Herbal and Alternative Medication Use among
Participants with Eating Disorder Symptoms.’ International Journal of
Eating Disorders 39 (August 2006): 741–746.
Swanson, J.K., and J. C. English 3rd. “Serum Sickness-like Reaction to
Pamabrom.’ Journal of Drugs in Dermatology 5 (March 2006): 284–286.
Thomas, M. C. “Diuretics, ACE Inhibitors, and NSAIDs— the Triple
Whammy.’ Medical Journal of Australia 172 (February 21, 2000): 184–
185.
Vertalino, M., M. E. Eisenberg, M. Story, and D. Neumark-Sztainer.
“Participation in Weight-Related Sports Is Associated with Higher Use of
Unhealthful Weight-Control Behaviors and Steroid Use.’ Journal of the
American Dietetic Association 107 (March 2007): 434–440.
Wiese, J. G., M. G. Shlipak, and W. S. Browner. “The Alcohol Hangover.’
Annals of Internal Medicine 132 (June 6, 2000): 897–902.
ORGANIZATIONS
American Academy of Child and Adolescent Psychiatry (AACAP). 3615
Wisconsin Avenue NW, Washington, DC 20016-3007. Telephone: (202)
966-7300.
American College of Sports Medicine (ACSM). P. O. Box 1440,
Indianapolis, IN 46206-1440. Telephone: (317) 637-9200. Website:
http://www.acsm.org
American Dietetic Association (ADA). 120 South Riverside Plaza, Suite
2000, Chicago, IL 60606-6995. Telephone: (800): 877-1600. Website:
http://www.eatright.org
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American Society of Health-System Pharmacists. 7272 Wisconsin Avenue,
Bethesda, MD 20814. Telephone: (301) 657-3000. Website:
http://www.ashp.org
Centers for Disease Control and Prevention (CDC). 1600 Clifton Road,
Atlanta, GA 30333. Telephone: (404) 639-3311. Website:
http://www.cdc.gov/
Dietitians of Canada/Les diététistes du Canada (DC). 480 University
Avenue, Suite 604, Toronto, Ontario, Canada M5G 1V2. Telephone: (416)
596-0857. Website: http://www.dietitians.ca
Herb Research Foundation (HRF). 4140 15th Street, Boulder, CO 80304.
Telephone: (303) 449-2265. Website: http://www.herbs.org
U. S. Food and Drug Administration (FDA). 5600 Fishers Lane, Rockville,
MD 20857-0001. Telephone: (888) INFO-FDA. Website:
http://www.fda.gov/default.htm.
Rebecca J. Frey, PhD.
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