Doctor Detective with Spencer Nadolsky

By Spencer Nadolsky, DO, Pn2

In this week’s case study, Dr. Detective investigates a healthy man with high blood pressure, and discovers the problems of medical self-diagnosis.

Eat less and exercise more. It’s generally a great prescription for improving health and improving body composition. However, it doesn’t always work.

Even with an awesome exercise plan and a rock-solid diet, some people suffer from mysterious symptoms and complaints that seem puzzling, given how much effort they put into their fitness and health.

When we meet clients who have problems that exercise and nutrition — not to mention their own doctors — can’t seem to solve, we know there are only a few experts on the planet to turn to. One of them is Spencer Nadolsky.

Dr. Nadolsky is a doctor of osteopathic medicine who’s also studied exercise physiology and nutrition. An academic All-American wrestler in university, he’s still an avid exerciser and brilliant physician who practices what he preaches to patients -– treating preventable diseases first with lifestyle modifications (instead of prescription drugs).

When clients have nowhere else to turn, Dr. Nadolsky turns from a cheerful, sporty doctor into a meticulous, take-no-prisoners forensic physiologist. He pulls out his microscope, analyzes blood, saliva, urine, lifestyle – whatever he has to, in order to solve the medical mystery.

When Dr. Nadolsky volunteered to work on a regular case study feature with us, we jumped at the chance. By following along with these fascinating cases, you’ll see exactly how a talented practitioner thinks. You’ll also learn how to improve your own health.

In today’s case, we’ll meet a healthy man with high blood pressure. In investigating this mysterious situation, Dr. Detective examines his own foibles and “blinders” — and reminds himself that the “obvious” solution… may not always be the correct one.

The client

Drew, a 54 year old male, came to my office for his yearly check-up.

Other than an operation to remove his appendix, Drew’s medical history was pretty clear, and he had no particular health complaints. With patients like him, I generally offer some preventative advice and screen for any brewing diseases.

The client’s signs and symptoms

Drew might not have felt bad, but glancing at his vital signs before walking into the examining room, I noticed a few warning signals .

His BMI of 27 was in the “overweight” category, and at 39″ (99 cm), his waist circumference was slightly higher than ideal. (Anything over 39-40″ is considered a risk factor for cardiovascular disease.) Even more importantly, his blood pressure was mildly high with a reading of 152/95 — significantly more than the “normal” cutoff of 120/80.

Quickly, I referred to the record of Drew’s visit from the previous year and discovered that back then, his blood pressure was 127/84. Hmm. My detective’s bloodhound nose sniffed a potential problem.

But when I walked into the room to greet the patient, nothing about his appearance seriously alarmed me.

While I examined Drew, he told me about his habits and the year’s events. He wasn’t taking any medications. He never smoked, rarely drank alcohol, worked a 9-5 cubicle job, was happily married, and regularly attended church.

It’s important to ask about these lifestyle choices to assess stress and other factors that may contribute to elevated blood pressure. But so far, I wasn’t learning much that would help explain his problem.

(A note about attending church: Spiritual folks tend to have less stress. This doesn’t mean you have to go to church; it just means you might benefit from some type of spirituality.)

Signs / Symptoms	My thoughts – potential issues
Elevated blood pressure	Weight issues, stress, sleep problems, atherosclerosis, kidney issues, thyroid, adrenal
Elevated body weight	Likely lifestyle factors, could be thyroid related, but not likely

Digging deeper

I didn’t have much to go on yet. But as always, I also asked about nutrition, exercise, and sleep habits.

Nutrition: Drew ate 3 times a day. His meals sounded like a typical American plate of excess processed starches. However, on the positive side, he wasn’t over-indulging in calorie-laden beverages (including alcohol), which I admired.

Exercise: Drew’s exercise regime included 20 minutes once a week on the elliptical, one session of racquetball per week, and one circuit-style weights workout per week using the machines.

Sleep: I was concerned that Drew might suffer from sleep apnea, but he claimed he has never snored and said he slept well for 7 hours each night.

Wearing blinders

Sometimes even good detectives make mistakes – we hone in on the most obvious explanation and attribute all problems to that cause. In medicine, we call it “going in with our blinders on.”

And with my blinders firmly in place, I went straight to Drew’s diet to “fix” him. I thought he was eating far too many carbohydrates. If he ditched those and lost his excess weight, his high blood pressure would magically disappear.

Okay, okay. I was jumping to conclusions. But in my own defence, weight loss alone will often solve high blood pressure.

For this visit, I asked Drew to increase his lean proteins at each meal and to cut his starches in half, replacing what was missing with green veggies.

(This is all very much in line with PN’s version of My Plate, and if you’ve read my previous cases you will notice these nutritional recommendations are pretty standard for me.)

I also ordered some standard labs both for screening purposes and to pinpoint possible secondary causes. We would discuss these labs at his next visit following his weight loss trial.

The tests and assessments

With Drew’s medical history, physical, and lifestyle habits, I assumed his labs would come back normal except perhaps his cholesterol panel and fasting blood sugar. Unfortunately, Drew didn’t actually get his bloodwork done until a few days before his follow-up, a month after his initial visit.

The test results

These are Drew’s pertinent lab findings:

Marker	Result	Lab Reference Range	Thoughts
Fasting glucose	89 mg/dL	65-99	Not too bad. No signs of insulin resistance here.
Sodium	144 mEq/L	134-144	Kind of high, but not necessarily a concern.
Potassium	2.8 mEq/L	3.6-5.0	Low and somewhat concerning. Possibly hyperaldosteronism in combination with the high sodium.
Creatinine	0.9 mg/dL	0.6-1.2	Kidneys seem to be fine at first glance.
HDL	50 mg/dL	40-90	Also not too bad. Could be higher but I will take it.
Triglycerides	90 mg/dL	40-150	Not too shabby. These were probably much higher before he started his new dietary habits.
Total cholesterol	208 mg/dL	Less than 200 (but doesn’t necessarily matter)	Elevated but not a significant concern. His Non-HDL cholesterol is fine at 158 mg/dL.

Based on his cholesterol/lipid panels, it was pretty clear to me that Drew had been following my nutritional suggestions. I wished we’d had a baseline panel to compare to his recent results, but sometimes we have to work with what we get.

A clue: Electrolytes and aldosterone

Despite his overall positive labs, I was concerned about Drew’s sodium and potassium levels . The previous year, these values had been normal. But now, the readings suggested a possible case of hyperaldosteronism (high aldosterone).

Aldosterone is a hormone made by the adrenal glands. It controls the body’s levels of sodium and potassium. With high levels of aldosterone, your sodium goes up and your potassium goes down. This can be dangerous because low potassium can disrupt your heart’s electricity and therefore its rhythm. Not good!

Hypokalemia (low potassium) can be caused by a number of factors, but given Drew’s blood pressure and his lab results, the high aldosterone hypothesis seemed the likeliest explanation.

But high aldosterone levels themselves have many causes. So I needed to figure out, not only if high aldosterone was really Drew’s problem, but also, if it was, what was causing it?

Quickly reviewing his records, I remembered that he’d said he wasn’t on any medications and didn’t have a family history of genetic disease or cancers. With so little to go on, I needed to order more testing.

I called Drew to let him know about the results and to give him a prescription for a small dose of potassium, as well as to send him for further labs. If his potassium had been even factionally lower I would have considered sending him for cardiac monitoring in the hospital, since the heart arythmias produced by hypokalemia can be quite dangerous.

The test I ordered was a morning plasma aldosterone:renin ratio. For those interested in delving further into this subject, I suggest the PN Certification but basically I was testing to see:

Whether Drew had excess aldosterone.
If so, did it result from overproduction in the adrenal glands or was it coming from other causes?

I also wanted to test Drew’s magnesium, because magnesium and potassium exist in a balance; if his magnesium was out of line this could itself explain his low potassium.

Drew agreed to my suggestions and scheduled his test for the next morning.

The test results, round 2

Blood chemistry panel: The plot thickens

Marker	Result	Lab Reference Range	Thoughts
Magnesium	2.3 mg/dL	1.8-3.0	Not the cause of Drew’s low potassium
Aldosterone	2.0 ng/dL	6-22	Definitely low
Renin	0.2 ng/mL/hr	0.29-1.9	Low

Instead of having high aldosterone, Drew had low aldosterone! What the heck was going on?

The only possible explanation was that something else was mimicking aldosterone in his body. His system was now responding by lowering his natural aldosterone in an effort to bring things into “balance”.

I needed to get Drew back in the office for some further investigation!

4 weeks after his initial visit, Drew came back.

With his new nutritional habits, Drew had managed to lose 5 pounds. I could tell he was proud of this achievement as he showed me how his belt was now buckled tighter, with excess leather at the end. Naturally, I praised him.

Then I glanced at his blood pressure. Still in the 150s/90s. I’d suspected as much, since I was now pretty sure that unlike most others, his weight wasn’t causing his high blood pressure.

But what was?

Why would his aldosterone be low? It just didn’t make sense. Something in the past year must have changed.

As I puzzled aloud about this, Drew’s facial expression suddenly changed.

“Well, I have been taking a new supplement,” he admitted.

Say what?

Mystery solved

Apparently, a year earlier, Drew had read an article about adrenal fatigue and decided that he must have the condition. The article recommended licorice root as a treatment, so he started to take it at very high doses.

Bad move!

But at this point in his story, his difficulties were finally starting to make sense.

Licorice root contains an ingredient called glycyrrhizin. Glycyrrhizin prevents the breakdown of cortisol in the kidneys. It can help those with adrenal problems but should not be taken without testing and a true diagnosis. That’s because in those without adrenal problems, higher cortisol levels will act like aldosterone in the kidney.

In Drew’s case, although he had low aldosterone levels, the inability to break down the cortisol in his kidneys made his body act as if he had high aldosterone (pseudohyperaldosteronism) — along with all its symptoms — high blood pressure, high sodium, and low potassium.

The solution was now obvious. But there were also some lessons applicable to all.

The prescription

Fix #1 – Stop the licorice root

Licorice root can be a very powerful treatment and just because it is a supplement, doesn’t mean it won’t have side effects. If a supplement works as a treatment then it also has the potential to cause problems if used incorrectly. Make sure you talk to your physician (osteopath, allopath, or naturopath) before starting licorice root.

Fix #2 – Continue with the nutritional habits

Drew had made great progress with his weight loss. And even though his weight did not appear to be the cause of his high blood pressure, keeping his weight lower would be much healthier for him in the long run.

The outcome

For the next little while, Drew returned weekly for blood pressure monitoring. Once he stopped taking licorice root, his readings began to come down into the 140s/90s and have now settled in the 120s/80s range.

Also, I checked his sodium and potassium levels a few weeks after he stopped taking licorice root and they came back normal. He was able to stop taking his daily potassium supplement as well.

Drew prided himself in his continued weight loss and now wanted a better exercise prescription in order to get “bigger muscles”. He was hooked on looking better for himself… and his wife. Success!

Summary

What can we take away from Drew’s story?

Always, always, always tell your physician everything you are taking — including medications and supplements. They might not ask specifically about them so it is important you mention it. (Shame on me for not specifically asking!)
High blood pressure isn’t always due to excess weight (although excess weight is often the cause). Generally, stress reduction and weight loss will reduce blood pressure, but if they don’t, there might be an underlying cause.