NICE: Blood Pressure Update

From Diagnosis and management of hypertension in adults. NICE guideline update 2019

BJGP Feb 2020 by Nicholas R Jones et al.

The last update by NICE was in 2011. The key changes are explained in this article.

High blood pressure is blood pressure over 140/90 if measured in the clinic.

Home measurements can be more reliable due to a natural rise in blood pressure in the clinic setting. Ambulatory monitoring can be done, but it is not always available or tolerated. My comment: The machine can be very uncomfortable and disrupts sleep. 

To take your blood pressure at home, take two readings, one minute apart, twice a day for 4 to 7 days.  Don’t count the first days readings. Then take the average of the others.

Hypertension is diagnosed if the average of home or ambulatory monitoring is over 135/85.

The BP should be taken standing for those people over 80, who have type two diabetes and if you have postural hypotension. You need to stand for at least a minute before taking the blood pressure and it is best to avoid talking. 

A blood pressure difference between the arms of over 15 mmHg is a marker for vascular disease. Thereafter the arm with the highest measurements should be chosen for monitoring.

Urgent admission is needed if the bp is over 180/110.

Target organ damage is assessed with looking at the retina, urine testing, U and E and eGFR, ECG and a cardiovascular risk score such as QRISK. Check up should be annually.

Lifestyle advice should be emphasised as this can result in taking fewer drugs.

People with blood pressures over 140/90 at the clinic or 135/85 who are aged 60 to 80 are currently advised to have treatment for their blood pressure. People over the age of 80 are fine with blood pressure targets lower than 150 systolic.

The treatment target for people with diabetes is now 140 systolic which is now the same as the general population.

The drugs to treat hypertension are:

ACE or ARB if type 2 diabetes, age under 55 or African or Caribbean origin.

The next step is to add a calcium channel blocker or thiazide like diuretic.

The next step is a combination of ACE or ARB, CCB and Thiazide.

If the potassium is less than 4.5, Spironolactone can be added as a next step.

If the potassium is over 4.5 then an alpha or beta blocker.

For all other patients the first step is a CCB or Thiazide. 

The next step is an ACE, ARB or Thiazide.

Then any combination of these.

If the potassium is under 4.5 then spironolactone can be added.

If the potassium is over 4.5 then an alpha or beta blocker can be added.

 

Fitter, better, sooner

From BJGP May 2020 by Hilary Swales et al.

Having an operation is a major event in anyone’s life. There is a lot a patient can do to improve their physical and mental health before surgery that will improve their recovery and long term health.

Fitter, better, sooner is a toolkit was produced by the Royal College of Anaesthetists with input from GPs, surgeons and patients.

The toolkit has, an electronic leaflet, an explanatory animation and six operation specific leaflet for cataract surgery, hysteroscopy, cystoscopy, hernia, knee arthroscopy and total knee joint replacement.

These can be seen at: https://www.rcoa.ac.uk/patient-information/preparing-surgery-fitter-better-sooner

The colleges want more active participation with patients in planning for their care.

The most common complications after surgery include wound infection and chest infection. Poor cardiorespiratory fitness worsens post op complications. Even modest improvement in activity can improve chest and heart function to some extent.  Keeping alcohol intake low can improve wound healing. Stopping smoking is also important for almost all complications. Measures to reduce anaemia also reduce immediate and long term problems from surgery and also reduce the need for blood transfusion. Blood transfusion is associated with poorer outcomes particularly with cancer surgery. HbA1Cs over 8.5% or 65 mmol/mol causes more wound complications and infections.  Blood pressure needs to be controlled to reduce cardiovascular instability during the operation and cardiovascular and neurological events afterwards.

This toolkit is already being used in surgical pre-assessment clinics but access to the materials in GP practices will also help. After all, the GPs are the ones who are initially referring the patients for surgery, and improving participation early can only be helpful.

It is hoped that this initiative will result in patients having fewer complications, better outcomes from surgery but also from their improved lifestyle.

 

Do you have a chronic disease or a long term condition?

Adapted from BMJ 23rd Nov 19. A chronic problem with language by Dr Helen Salisbury

Helen is a GP in Oxford she writes…..

Some years ago I was told the term “chronic disease” had been replaced by “long term condition”. When I asked my non medical friends about it, they thought that both “chronic” and “acute” both meant “severe”.  My comment: whereas they mean something more like “long lasting” and “short lasting” to a doctor.

So a chronic disease sounds like one likely to harm or kill you, whereas a long term condition sounds like something you live with but not die from. As doctors now copy patients into their letters, then perhaps we need to be more responsive to their beliefs?

Impaired renal function, from natural ageing is one of the problems that has arisen from the misunderstanding of the term “chronic kidney disease”.  It can cause people real worry because they imagine that they are a candidate for dialysis or death, yet they are unlikely to be affected symptomatically, nor is it likely to hasten death. Heart failure is another term that causes a lot of distress.

Sometimes doctors need to be precise in their speech and letters to each other so we can’t abandon all technical language.  Copying clinic letters to patients is good practice, even if patients sometimes struggle to understand them completely, because they have a record of the consultation and a chance to clarify the decisions made.

Sometimes we could use more lay terms to reduce confusion. Abandoning “chronic disease” is a good start.

 

 

Dr Chris Palmer: Ketogenic diet now being used in mental health

Dr Chris Palmer from Harvard has been using the low-carbohydrate and ketogenic diets in practice for over 15 years now mostly for weight loss. Recently, he has found an anti-psychotic and mood stabilizing effect from specific types of the ketogenic diet. Now he is pursuing clinical research in this area to better understand the topic. As a result, he has also been speaking at national and international conferences.

Here area few of his podcasts/interviews:

http://lowcarbmd.com/episode-49-dr-chris-palmer-treating-schizophrenia-with-lifestyle

https://www.chrispalmermd.com/ketogenic-diet-psychology…/ and keto putting schizophrenia into remission.

https://www.chrispalmermd.com/ketogenic-diet-remission…/

https://www.chrispalmermd.com/keto-naturopath-by-karl-goldcamp-interview-christopher-palmer/

My comment: It is a very good idea for those people with schizophrenia to be on a low carb diet, mainly due to the side effects of the anti-psychotics which give people metabolic syndrome and diabetes. It is even better to hear that there conditions are improved so they are less reliant on these drugs.

Diet doctor: free online course with credit for medical professionals

This is a message from dietician Adele Hite:

I am thrilled to announce that Diet Doctor is now offering a free CME activity to all interested clinicians, patients and carers: Treating metabolic syndrome, type 2 diabetes, and obesity with therapeutic carbohydrate restriction.

Thanks to the support of our members, we can offer this CME at no cost to clinicians.

This fully referenced, evidence-based CME activity is certified for three AMA PRA Category 1 Credit(s)™. It is jointly provided by Postgraduate Institute for Medicine (PIM) and Diet Doctor and is intended for physicians, physician assistants, registered nurses, and dietitians engaged in the care of patients with metabolic syndrome, type 2 diabetes, and obesity.

The course was designed by clinicians for clinicians. As this course outline shows, it covers all clinicians need to know about dietary carbohydrate restriction and how to implement it safely and effectively with patients for whom it is appropriate. In keeping with Diet Doctor’s mission to “make low carb simple,” the course also comes with supplemental materials for clinicians and their patients to make it easy to translate evidence into practice.

We hope that this course will help reaffirm the scientific and clinical support for this approach and — along with other efforts by LowCarbUSA and expert clinicians — act as another step in solidifying a standard of care around low-carb nutrition. We would love it if you would share the news about this course with colleagues. You can forward this email to them or use this flyer to share or post.

Diet Doctor also has some new resources to help make low carb simple for patients and clinicians alike. For patients, we have:
‒ a sample menu
‒ shopping list
‒ a meal planning guide
‒ a substitutes for favorite foods handout
‒ simple meals and planned leftovers, and
‒ information about target protein ranges

For clinicians, we have handy one-pagers on:
‒ monitoring ketones
‒ fasting insulin and HOMA-IR ranges
‒ lab tests and follow-up schedule
‒ type 2 diabetes medication reduction, and
‒ a 5-day food diary for patients who need to monitor their intake

Of course, for those on the list who are not clinicians, anyone can register for and view the course. You just won’t be eligible for CME credits.

For clinicians, please let us know if we can help you help your patients in other ways. And if you are interested in supporting us as we continue to develop materials to make low carb easy for clinicians and patients, please think about becoming a Diet Doctor member yourself.

Finally, we are happy to hear suggestions for improvements moving forward. If you take the time to view the course, we’d love to hear what you think.

Best regards,
Adele

Nina’s plea: Would you write to Congress and change USA food guidelines?

This is a message from Nina Teicholz, writer and low carb activist:

My highest concern about the existing USA Food Guidelines is for the people who have no choice but to eat the food that they are given, which is based on what is thought of as “a healthy diet”. There are many essentially ‘captive’ populations in schools, hospitals, and prisons. Many of these people are the most disadvantaged among us. Native Americans on reservations have no choice about the food assistance they receive.

I’ve spoken with the Native American woman who for years has been trying to change the USDA food they get, and she cannot get even the tiniest change. They desperately need the food, yet it’s more than 50% carbs, and something like 40% of the kids on these reservations have diabetes.

The same is true for poor people, education programs, and feeding programs for the elderly. These people have no choice.  No other food  is given to them. Many doctors also say they have no choice, because  they are required to teach the guidelines to patients. It is the same thing in most federally funded institutions.

Thus, my hope is, if we have to have Guidelines for the time being, that they do as little harm as possible. The Guideline is coming up for review, but the committee have already decided not to review the evidence on low carb diet studies.  We are seeking to change this, and there is already some support for our position, that these studies should be included in the evaluation. Could we get in a low-carb option? Could we force them to consider all the science on saturated fats? This next set of Guidelines will come out by the end of this year, and I think there is still time to try to force change. Our actions now would build awareness around the issue that there is something wrong with the Guidelines. There is so little awareness of the problems. And actually I’m hopeful,  because in the last few months, we’ve worked with a number of groups to raise awareness to a level it’s never been before.

Here’s what I would suggest for now.
Both my group, The Nutrition Coalition and the group Low-carb Action Network,  have webpages that make it very easy for you (if American) to write/call your Members of Congress. This is super important and I urge everyone to do this. USDA is not budging. Congress is really the only body of power interested in change, and they need to hear from people. So I would urge everyone to contact their members of Congress. It can take just a few min.

Thank you,

Nina

My comment: If the USDA food guidelines are changed, it would make it so much easier for the UK to follow. The photograph shows the breakfast given to a diabetic patient in a US hospital who had just had a heart attack. The UK also dishes out abysmal food to its patients. Wouldn’t it be great if they had a low carb option?

Public Health Collaboration conference online a great success

The Public Health collaboration online conference 2020  was very successful.  The videos are available on You Tube for free making the conference even more accessible for everyone who needs advice on what to eat to stay healthy.

If you are able to contribute to the PHC fund to keep up our good work please do so. Sam Feltham has suggested £2.00.  This is via the PHC site.

This year there were contributions from mainly the UK but also the USA.

Visitors to this site will be very pleased to know that keeping your weight in the normal range, keeping your blood sugars tightly controlled, keeping your vitamin D levels up, and keeping fit from activity and exercise, are all important factors in having a good result if you are unfortunate enough to be affected by Covid-19. We have been promoting these factors in our book and website for several years now, mainly with the view to making life more enjoyable, especially for people with diabetes, now and in the future. The reduction in the severity  to the effects of   coronavirus is a side effect of these healthy living practices.

Several talks went into the factors and reasons for this, but in a nutshell, if you are in a pro-inflammatory state already, you will have a much more pronounced cytokine inflammatory response to the virus than is useful for clearing the virus, and you end up with inflammed lung tissue which leaks fluid thereby impairing your blood oxygen levels.

A talk that I found particularly apt was the talk from a GP who had had a heart attack at the age of 44 despite a lack of risk factors except for massive stress. He gives a list of self care practices that helped him. I would also include playing with your animals. Emma and I are cat lovers and can vouch for this!

My talk is about VR Fitness, which was the only talk this year which was specifically exercise related. The Oculus Quest has only been out a year and has been sold out since shortly after New Year. I was fortunate enough to buy one in anticipation of my imminent retirement, and it has been great as an exercise tool over the long, cold, dark winter and more useful than I had ever anticipated over the lockdown as a social tool.

There were several very professional cooking and baking demonstrations on the conference this year, and indeed, this could not have otherwise happened on a traditional stage format.  We had low carb “rice”, bread, pancakes and pizza demonstrations which may well help you if you prefer to see how it is done step by step or if you want to broaden your repertoire.

I was particularly taken with the pizza base idea from Emma Porter and I will follow up with this in a later post.  The whole video is available from the PHC  site which takes you to all the videos on You Tube.

 

 

 

Self caring during illness

Adapted from online presentation by Beverly Bostock ANP 7 May 2020

If you have diabetes you are more at risk of serious complications from Covid-19 and should seek medical advice early in the illness.

Any febrile illness can raise your blood sugars, including the prodromal phase when you don’t otherwise have symptoms. Once you are aware that you are coming down with something there are some useful ways of remembering how to monitor yourself.

Particularly for insulin users:

S – SUGAR – check your blood sugar more frequently than usual. For instance, if you would normally check your blood sugar every 5 hours during the day, double this to every 2.5 hours.

I – INSULIN – Adjust your insulin according to your blood sugars to keep within your target blood sugar level.

C – CARBOHYDRATE – If your blood sugar is low eat or drink more glucose or sugar/starch food items. If your blood sugar is high, drink plain water or more diet drinks.

K – KETONES – Use blood ketone stix or urine ketone stix to monitor your ketones if you are a type one diabetic every 4 hours or so. This is particularly important if you feel very ill, are nauseated, vomiting or have abdominal pain. If your ketones are high consider extra insulin, keep well hydrated and alert medical staff sooner rather than later.

Particularly for type twos:

It is important to keep well hydrated when you experience any illness but particularly an illness where you are febrile, or have  vomiting, limited oral intake, or severe diarrhea.

Some drugs can worsen your response to dehydrating illness and you may need to seek advice from a doctor, nurse or pharmacist about stopping certain drugs and when it is appropriate to restart them.

You can remember what they are with the mnemonic: SADMAN

SGLT2 inhibitors, ACE inhibitors, Diuretics, Metformin, ARBs, and Non- steroidal anti-inflammatory drugs.

 

 

 

New diabetes calculator helps determine if you are type one or type two

New calculator improves diagnosis of diabetes
Lynam A & al. BMJ Open 26 Sep 2019
curated by Pavankumar Kamat UK Medical News 30 Sep 2019

Scientists have developed a new calculator tool to help clinicians determine whether a patient has type 1 or type 2 diabetes, ensuring appropriate treatment and fewer complications. The beta version of the calculator is available here.

https://www.diabetesgenes.org/t1dt2d-prediction-model/
Determining the type of diabetes remains a challenge for clinicians, and current blood and genetic tests are not robust enough to provide a definitive diagnosis. The tool utilises a model that incorporates patient data (age of diagnosis and body mass index) and blood test results to provide a personalised approach.

It is useful in determining the likelihood of type 1 diabetes in patients, thereby reducing misdiagnosis.

Researchers at the Universities of Exeter, Oxford and Dundee analysed data on 1352 individuals with diabetes and tested the calculator in an additional 582 individuals.
The new tool follows the footsteps of another calculator previously developed at the University of Exeter which helps clinicians determine the presence of diabetes sub-type MODY. The tool has been successfully used by more than 100,000 people.
Dr Angus Jones, the lead researcher, said: “The right diagnosis in diabetes is absolutely crucial to getting the best outcomes for patients, as treatment is very different in different types of diabetes. Our new calculator can help clinicians by combining different features to give them the probability a person will have type 1 diabetes, and assess whether additional tests are likely to be helpful.”
References
Lynam A, McDonald T, Hill A, Dennis J, Oram R, Pearson E, Weedon M, Hattersley A, Owen K, Shields B, Jones A. Development and validation of multivariable clinical diagnostic models to identify type 1 diabetes requiring rapid insulin therapy in adults aged 18-50 years. BMJ Open. 2019;9(9):e031586. doi: 10.1136/bmjopen-2019-031586. PMID: 31558459