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Low carb for doctors: blood-pressure medications

Regarding blood pressure medication
and blood pressure itself… I always begin of course
with a baseline measurement. And are we happy
with that baseline measurement? Is any action needed
right to the beginning? Is the blood pressure very high? Or sometimes it’s surprisingly low. The next thing to add in is, “What are
the patient’s hopes around their medication?” So often if you asked that question
they’ll say, “I’d quite like to get off
some of my medication.” And then you might say, “Is there any particular drug
that you’d like to come off?” Fairly enough have a patient
addressed this very question only a few days earlier in the week and this was a patient who said, “I’m pretty certain amlodipine
is giving me ankle swelling and pain.” So for her one of her main motivators
was to come off amlodipine and that’s great because that
was my motivation as well. So that you’re blending patient safety,
the blood pressure as it is now, the patient’s hopes and then
you may have some things of your own. If the patient is on diuretics
for instance you know that bendrofluazide
may well be affecting the blood sugar, so that for you might be a priority
to get patients off that particular drug. And then I suppose the next thing is explaining to patients
what they might expect. So if they have signed up to this
seriously and they lose weight you would hope that their blood pressure
is going to improve. And again you would couch this
or frame it in terms of an improvement
rather than a risk. I suppose there is a risk that they will
stand up and feel dizzy and fall over, but actually that doesn’t happen
very often. This is more of an opportunity. And so I am always pleased if the patient is interested
in monitoring their own blood pressure. I’d give me a far more information
as a basis for decision-making in the future. But also it gives patients feedback,
so they are always coming in with lists of half blood pressure
that they’ve taken themselves and the blood pressure is improving. So that is great feedback for your patient
when they’ve taken the blood pressure and they know it’s improving. Plus if you’ve explained to them that they might feel dizzy at times
if their blood pressure drops and that might be an opportunity
to reduce medication, they will then make an appointment early
and sort this out with you, because their expectations
are appropriately set. As I pointed out already there is some
medications that are of particular interest and I come back again to diuretics, because of the side effects of gaunt and their worsening of renal function
that can be experienced and also the fact they are diabetogenic. A particular word on amlodipine. I’ve come across so many times
where a patient has swollen ankles as side effect to amlodipine
and is a tragedy. They’ve been put on diuretics
to treat the ankle swelling that really originated in amlodipine. So just is worth keeping an eye open for anybody with swollen ankles
who is on amlodipine, because that might be the cause and you might solve it so easily
with some weight loss. So there we are,
establish a baseline, are you happy with it,
is the patient happy with it, what are the patient’s goals
as regards their own medication, have they any worries or concerns…? And then what are your goals
with the medications? Have you got any worries or concerns
or things you’d like to change, so that between you,
you can come up with a plan encompassing your shared hopes for this? And point out, if they lose weight it is so likely the blood pressure
is going to improve. That’s what you can expect. So thinking about my own clinical experience
around blood pressure, I’m getting average drops in the systolic,
something like 10 mmHg, is quite common. And the diastolic doesn’t drop quite as much,
maybe 7 or something like that. It drops I’d say fastest
in some of the heavier patients who get initially
very great weight losses and they worth watching particularly. The blood pressure I find
usually plateaus out in the first year, somewhere like that,
and then stays pretty constant. I haven’t had any surprises later on. So you’ll get your greatest improvement
probably in the first few months. And it’s that time when it’s worth doing
those blood pressures a bit more often and alerting the patients
to what they might expect. So this blood pressure control is a great
aspect of the low-carb diet, really.

Randall Smitham



  1. Emile Jarreau Posted on December 12, 2017 at 10:21 pm

    Dr. Unwin is very articulate and sensitive to "reframing" the language needed these days in explaining thoroughly the corrective actions needed with his patients.

    Current corporately run U.S. hospitals are caught in a profit model that allows the doctor to spend only minimal time actually helping each patient.

    The series of many of the videos "Diet Doctor" is showing has been excellent.

    I'm a new fan