Why is High Blood Pressure So Hard to Manage?
Despite known lifestyle changes and relatively inexpensive and readily available medications, individuals with heart risk or hypertension are not managing their condition. Why?
How is it that with so many campaigns about the dangers of high blood pressure and such clear guidelines for treatment, there are still so many people at risk?
- 1 in 3 adults in the U.S. suffers form high blood pressure
- High blood pressure is the reported primary cause of death for 350,000 Americans a year
- Over half of people with high blood pressure, don’t know they have it
- Of those individuals who are aware they have high blood pressure, 67% don’t have it under control
- Health care costs related to high blood pressure and associated heart risk is closing in on $350B a year. It dwarfs the frequency and cost of all other diseases in the U.S.
4 Reasons High Blood Pressure is So Hard to Manage
1) Understanding - Denial and gambling
Individuals with hypertension or heart risk, tend not to view it as an on-going, degenerative disease, but rather as a temporary state ("I don’t really have high blood pressure. I just need to reduce my stress levels!") or as a risk factor for heart attack or stroke ("I’ll take my chances that a catastrophic event will not occur in the next few years").
This perception can be contrasted to people with another chronic condition, diabetes. They recognize their condition as a life long disease, that needs to be managed daily. People with hypertension however, think of it as “the silent killer” that suddenly strikes out of nowhere.The reality is that high blood pressure is a state of progressive chronic damage to the vascular system, which when left unchecked, gradually effects the heart, kidneys, brain and retina. The cells of these organs will not regenerate once the damage is done.And it’s not just an old age problem. 1 in 5 young adults suffer from high blood pressure which can lead to heart damage by middle age.
2) Top-of-Mind - If I can't feel it, it must not be that bad
With Diabetes there are serious day to day consequences of not managing your blood pressure. Thy symptoms are overt. You feel weak jittery or you faint. So the condition is always top-of-mind. When you exercise, when you eat, when you have a long day ahead - diabetes is always there to scare you "to be good".With high blood pressure, there usually are no overt symptoms. Your arteries hardening every day doesn’t feel like anything. Because of this, high blood pressure is not top of mind. The only times you think about it are when you get a scare or your doctor nags you.So how do you reinforce people for changing their diets, lifestyle or adhering to prescribed medication to reduce high blood pressure when they have no obvious symptoms to see success at controlling?
3) Discouragement - You always loose
Anyone who has had to diet or tried to start a new exercise regimen, knows how difficult and discouraging this can be. If you have high blood pressure you will never hear the “You are healthy like a ox. Keep it up!" from your doctor. It will always start with "things are not good". Then they give you long list of things you need to change in your life (see impractical advice below).Employer wellness programs that “force” you to get yearly health assessments or "incentify" you take part in group fitness classes and competitions, only exacerbate the problem. To begin, you get a much lower score on your health assessment than people without chronic conditions (demotivator #1). Then you are compelled to participate in group fitness challenges and "compete" with other people that don't have high blood pressure. Again you will always lose (demotivator #2). Why even bother trying? These people don’t have the same environment or genetics as you and you don’t do as well so you end up feeling even worse about yourself and more discouraged.
In the best case, you avoid being exposed to anything that reminds you of your health issues and limitations. In the worst case, you end up in complete denial.
4) Impractical advice - The "you need to change everything" approach
Most doctor's advice is - eat better, exercise more and lose weight. What doctors are actually asking patients to do it to change everything in their lifestyle and lose weight to avoid this unfelt threat.
People don't change over night and they can't accelerate from 0 to 60 in 10 seconds. If you ask a person with really poor eating habits to stop eating junk food, avoid bacon, stop drinking orange juice and switch to salmon, broccoli, quinoa and 96 oz of water, all over night - it just wont happen. If you set a bar of 10,000 steps a day for a person that is currently walking 200 steps a day, it just won't work. The person will fail.It’s not that they are lazy or lack willpower. The advice is simply not realistic or in line with known principals of habit formation. Advice needs to be personalized and implemented very gradually based on a person’s current lifestyle. People need to be able to see and feel their progress and get encouraged by each little win. I would even say people need to enjoy the process so that it can become a lifelong habit
6 Reasons Hello Heart Mobile Therapeutics Works
1) You are rewarded for tracking, caring and learning about yourself, not reducing BP or losing weight - you always win!
With tracking the goal is tracking, not an end destination of lowering blood pressure or losing weight. The latter are things you can fell pressured by, fail at and get discouraged. How many people have set goals to lower their blood pressure lose weight or control their blood sugar – and failed?
"I'm going to cut out all carbs for a month""I'm going to lose 10 lbs. by Thanksgiving""I'm going to walk 10,000 steps every day"
These end goals are not realistic and importantly they are not fun. You try them again and again but you fail in the long term. To anyone with a chronic health condition, the repeated failures can be very discouraging. (Interesting tidbit: Before the age of 45 women try and fail at 61 diets on average).But tracking is easy. Getting insights about yourself is engaging. Every time you track or check for an insight, you feel accomplished (i.e. get a positive reinforcement), simply by caring about yourself. Anyone can be successful. You do not get discouraged because you haven’t achieved some long-term, possibly impossible goal. You win every time you track, check how you are doing or check the daily insights. These simple wins (reinforcers) start rewiring the brain to continue the behavior. You stay engaged so you can start building simple habits.
2) To generate long term change and feedback loops you have to understand what's going on
When you have no idea if 145/90 is good or bad or when you hear that "your cholesterol is not good" it's as informative is telling you that the weather is going to be not good tomorrow. What does it mean? Should I take a jacket or start packing up sand bags around my house? When you get a personalized analysis with friendly explanations that help you understand what your BP and lab results mean, you start to acknowledge your condition and don't deny it or gamble on your health.
When you understand how your blood pressure changes over time and how bad or good it really is, you feel empowered to change it. Without understanding most people just shut it out. Without understanding, it's impossible to link our actions to the consequences to our health and create feedback loops.
3) You develop intrinsic motivators that sustain you for delayed rewards
Lowering blood pressure or losing weight are not immediate. They take time. So there is a significant delay between the action (changing diet or exercising) and the reward (reducing BP or losing weight). Contrast this to eating something heart or weight unfriendly. There is an immediate reward (taste or sugar high). In popular culture this is often referred to as immediate vs delayed gratification.To successfully change complex behavior you have to find a way to bridge the gap between the behavior and the reward. One very powerful way to do this is to help an individual develop intrinsic internal reinforcers. In the case of tracking, when the reward focus is shifted from lowering BP or losing weight, to tracking and finding out insights about themselves, people start developing internal motivations and rewards. Tracking has become its own reward (when the app has the right UX). So when you eat healthy and track, you get an immediate, contextually relevant reward (rather than some arbitrary point system or award).
4) Health remains top-of-mind in a positive way - daily, everywhere you go
When you track regularly and read your daily insights - your health remains top-of-mind. It's on your phone so it's with you everywhere you go and part of your daily routine (the average Amercian interacts with their smartphone 4.7hrs/day). With blood pressure tracking, you engage a minimum of twice a day. With diet, it is every time you eat (or better before you eat). Denial goes out the door.Since you are rewarded for tracking and adding data, you form a habit around tracking that keeps your health front and center. But that makes it very easy for you to notice how you're eating and make little shifts in your behavior. So instead of 3 pieces of toast you have 2. Instead of walking your dog for 5 minutes you take him on a 10 min walk. The shifts are small rather than dramatic because it is just a little self-awareness. But small, slightly satisfying shifts in behavior, introduced gradually, is the only successful strategy for developing long terms habits that can chain into complex behaviors.
5) Tracking can be easily sustained long enough to become a habit
New habit formation takes time - on average 60+ days. Diets are easy to sustain for 2 weeks. They get really difficult after that. Which means that long term changes in behavior don’t have a chance to develop. Tracking and reading personlized tips on the other hand, are easy to sustain long term - long enough for them (and the modest behavior shifts) to become established as habits.
6) Small steps add up to life-defining change
Instead of trying to walk 10,000 steps a day — beginning tomorrow — try parking one car farther from the front door at work every day, or get off one stop earlier on public transit and walk the remaining short distance. That you can do successfully every day. It's easy. It's slightly satisfying and even enjoyable.Don't stop eating fast food compleyely and give up on all the things you love (e.g. bacon, beer, cheese) just add avocado to your dinner. Or add a vegetable to your lunch. That's doable. Start small. You should feel that each new tiny habit is laughably easy on its own.You slowly build up little habits that chain together into important changes. And you enjoy the process. You don't have to suffer to be healthy!