Getting ‘Upstream’ in Health (and using a little ‘Nudging’ to Help Manage Long-Term Health and Wellbeing)
In an address to the American Heart Association in 1974, physician John McKinlay described his frustration with medical practice using the analogy of a rapidly flowing river to represent illness. He suggested that physicians are typically so caught up in constantly rescuing ‘victims’ from this river that they have no time to look upstream to see who is pushing their patients into the water (a story repeated by Dan Heath in his book called “Upstream” in 2020). He further suggested that too many people in healthcare were engaged in “downstream endeavors,” which he characterized as short-term, problem-specific, individual-based interventions. As a result, he said that they should refocus and look upstream, where the real problems mostly lie and learn our broad lessons for how to intervene from that vantage point.
Of course, it’s not only doctors or other medical professionals that focus on downstream ‘sickness’ problems when they occur. Many of us as individuals will often default to a reactive, “I’ll deal with problems when they occur” mentality, and perhaps even make matters worse by engaging in a number of behaviors and actions that we know may well have negative ‘downstream’ consequences, even as far as our health is concerned (such as poor eating or failing to engage in exercise (of which we will have more to say later!). And, of course, we have many ‘downstream’ health problems that we may have to manage. Some of the more significant ones are Heart disease, Stroke, Diabetes, Kidney disease, Depression, and even Dementia, in later life mostly. Less significant than these but nonetheless serious (and experienced at scale) are health problems such as obesity, vision loss, bone loss, sexual dysfunction, mental anxiety, and even Headaches. What isn’t widely appreciated is that ‘upstream of all of these as a major cause is hypertension -seen by the World Health Organization to be the world’s most impactful and widespread disease and therefore ‘upstream’ problem that we will focus on, as an example, in the rest of this article!
What is hypertension and why does it occur/arise (medically)?
At the most basic level, hypertension (also called High blood pressure) occurs when a person’s blood moves through his or her arteries at a higher pressure than normal. Of course, blood pressure is written as two numbers. The first (systolic) number represents the pressure in blood vessels when the heart contracts or beats. The second (diastolic) number represents the pressure in the vessels when the heart rests between beats. A person’s blood pressure changes throughout the day based on his or her activities. For most adults, a normal blood pressure is less than 120 over 80 millimeters of mercury, which is written as the systolic pressure reading over the diastolic pressure reading — 120/80 mm Hg. An individual’s blood pressure is considered high (and he or she is ‘hypertensive’) when he or she has a consistent systolic readings of 125 mm Hg or higher or diastolic readings of 80 mm Hg or higher.
What are generally regarded as ‘modifiable’ risk factors leading to hypertension include unhealthy diets (excessive salt consumption, a diet high in saturated fat and trans fats, low intake of fruits and vegetables), physical inactivity, consumption of tobacco and alcohol, dealing with considerable personal stress and being overweight or obese (and there are other contributors too). And what are generally regarded as ‘non-modifiable’ risk factors include a family history of hypertension, particular ethnicities, being over 60 years of age or older and co-existing diseases such as diabetes or kidney disease.
What is the experience of having hypertension?
Many people with high blood pressure experience general discomfort, headaches, nosebleeds, or a little shortness of breath, minor buzzing in the ears, etc. and can live with this broad discomfort for many years (and not even realize they have hypertension, in many cases). However, those symptoms can become more serious and then start to lead to many other health problems (serious or non-serious) if not addressed by both life-style changes, of which we will have more to say later, or treated by drugs) In the absence or either of these, blood-pressure can reach dangerously high levels and even lead to life being threatened.
How do we best address the problem in general?
Although we’ll talk subsequently about how we might address hypertension issues both naturally and then medically, it is important to appreciate that it is much better to solve for hypertension problems, at least initially, at an individual rather than generic level (and then extrapolate our findings to envelope wider populations that may be similarly affected and then treatable-the health of the community). In other words, the more we can avoid generalized approaches and tailor our interventions to individual needs (often at a very personal level) the more successful we are likely to be, and we can then extrapolate to wider cohorts that may be helped with a ‘library’ of broadly similar interventions that we can build up and honed over time.
How do we best address the problem naturally?
Lifestyle adjustments are the standard, first-line treatment for hypertension. A few specific recommendations that a typically made here are therefore as follows:
· Regular physical exercise: Current guidelines recommend that all people, including those with hypertension, engage in at least 150 minutes of moderate-intensity, aerobic exercise every week, or 75 minutes a week of high-intensity exercise. People should therefore exercise on at least 5 days of the week. Examples of suitable activities are walking, jogging, cycling, or swimming.
· Avoiding poor food choices: Lowering salt intake can benefit people with hypertension. In addition, a diet with as little saturated and total fat as possible is recommended (with more whole grain, high fiber foods, a variety of fruit and vegetables, beans, pulses, and nuts, and more fish in the diet). Of course, little or no ‘junk food’ helps greatly too.
· Lessening/eliminating substance abuse: People are recommended to limit or even avoid consuming alcohol, recreational drugs, and tobacco, to better cope with stress, as these can contribute to elevated blood pressure and the complications of hypertension. Avoiding or quitting smoking reduces the risk of hypertension, serious heart conditions, and other health issues.
· Reducing Stress: Avoiding or learning to manage stress more effectively can help a person control blood pressure. Meditation, greater mindfulness warm baths, yoga, and simply going on long walks are relaxation techniques that can help relieve stress for many people.
· Improving sleep quality: Avoiding the use of OTC or prescribed drugs, sleep quality can often be improved by simple changes. These include switching to a personally more comfortable pillow, darkening the bedroom more, lowering bedroom temperature, and sticking to the same ‘go to bed’ and ‘wake-up’ time as much as possible. It’s also important to avoid late eating and drinking.
How do we best address the problem medically?
Although it is clearly a poor second to so-called ‘natural’ or non-drug treatments it is important to realize that hypertension may need to be treated with drugs (especially when blood pressure is high on a sustained basis). It is therefore important to appreciate that hypertension occurs in 4 increasingly elevated stages as follows:
· Pre-hypertension. This usually means that blood pressure is over 120 mm but under 130 mm systolically and over perhaps 75mm and under 85 mm diastolically. This is sometimes treated with drugs, but a natural or more lifestyle-oriented change is more likely to be a better first course of action here in most cases.
· Stage 1 hypertension. Stage 1 hypertension is typically a systolic pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg. As for pre-hypertensive people, some low-dose drugs may be prescribed here but more commonly lifestyle changes are more likely to be recommended.
· Stage 2 hypertension. More severe hypertension, stage 2 hypertension is typically a systolic pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher. Drugs in higher doses are more likely to be deployed at this level, although natural treatments are still partly recommended.
· Hypertensive crisis. A blood pressure measurement higher than 180/120 mm Hg is an emergency situation that requires urgent medical care and may only be treated or improved with drug treatment (at least in the short term).
As we suggested above, most physicians will often recommend a low drug dose at first, mainly because antihypertensive medications may have minor side effects, but these may then need to increase over time and depending on the impact. Eventually, people with hypertension will need to combine two or more drugs to manage their blood pressure. Medications for hypertension include:
- diuretics, including thiazides, chlorthalidone, and indapamide
- Beta-blockers and alpha-blockers
- calcium-channel blockers
- central agonists
- peripheral adrenergic inhibitor
- angiotensin-converting enzyme (ACE) inhibitors
- angiotensin receptor blockers
Of course, the choice of medication depends on the individual, the group to which they belong (often gender, age, ethnicity, and other medical conditions), and any underlying medical conditions they may experience.
Can behavioral economics/nudging help and why?
Whether we are looking to use more natural or drug-related interventions for people with minor or major hypertension, most physicians can only offer a ‘treatment pathway’ and it is then mostly up to the patient to follow it. For some people, this may work well and without any outside help or ‘push’. However, for most people, a little help is both useful and necessary and one relatively new field is behavioral economics (or ‘choice architecture’ or ‘nudging’ in more popular language).
Nudging, according to Nobel Prize-winning economist Richard Thaler (who wrote the book ‘Nudge’), is something that influences behaviors without forcing anyone’s hand in ways that make them uncomfortable. Thaler suggested that this approach is “any aspect of the choice architecture that alters people’s behavior in a predictable way without forbidding any options or significantly changing their economic incentives”. In other words, effective nudging, as it relates to health, is about ‘guiding’ individual choices towards outcomes that are palpably ‘good’ for them in health outcome or wellness terms. This might be simple prompts, like alerts and reminders, to take a medicine or engage in some simple exercise from time-to-time, or more sophisticated incentives (including monetary and other rewards in some cases) that encourage a person to avoid a poor behavior and instead engage in a ‘better’ one.
What are some nudging examples?
Nudging can take many forms and can operate at broad policy or personal level.
An example of policy level might be switching from an ‘opt out’ versus ‘opt-in’ approach.
One example here in the US are States like Texas, which uses an ‘opt-in’ approach to organ donation, resulting in the donation rate being 17% of the population, whereas in Indiana, which uses an ‘opt-out’ approach to organ donation, the donation rate is 69% of the population.
An example of personal or individual level nudging might be looking to get people to eat less ‘junk’ food and more healthy choices (and lower their blood pressure). To do this we might either give people a reward (gift voucher or real money) for eating salads every week (lifting the reward for each salad consumed). This can make significant differences in people’s behavior, which can often then ‘stick’ as they change their eating habits without incentives. This approach clearly applies to many other so-called ‘healthier’ behaviors including not missing screening or health check-up appointments, giving up smoking cigarettes, for example, exercising or even taking active steps to relax more.
Inevitably, as well as a ‘nudge’ may be designed, its effectiveness is still dependent upon it working on a particular individual, and he or she may not want to give up a habit or behavior that has been in place for weeks, months or even years (it is much easier to be a ‘couch potato’ and not exercise or keep buying that ‘fast food’ that tastes so good!). This means that we can’t rely on nudging alone to change people’s behavior and we need other mechanisms to help, including direct supervision, as much as this may be needed. However, it is also important to note that a single ‘nudge’ or ‘choice architecture’ may be effective on some individuals and not others. We should therefore be ready to design or re-design and try other nudges that may work more effectively (and in all cases be patient, as even tiny changes in behavior can be significant and built upon).
So, what does ‘nudging’ success potentially look like and what are the possible payoffs?
As most of us realize, we live in a culture in which people are often seduced and induced to adopt unhealthy behavior (especially via advertising across multiple channels). Given that we can’t easily stop this particular ‘train’, behavioral economics offers a very real opportunity to counter this trend, and the payoffs could be huge. Not only can individuals potentially be encouraged to shift their behavior (a little or a lot) with this approach, but the healthcare system at large (and particular the 3 ‘P’s’ of Providers, Payers, and Pharmaceutical companies) can benefit greatly too. For example, Providers like hospitals can reduce patient readmissions, Healthcare Payers (commercial ones and self-insure employers for instance) can lower the costs of extended treatment, and finally, Pharma can increase adherence to a course of drugs (saving long term costs and helping to hasten patient recovery). This means that we have many stakeholders in the health sphere that have a vested interest in designing better choice architecture that leads to greater overall wellness. This may well depend on a deeper level of individual case assessment to really understand a person’s current situation and motivations, and the context in which they perhaps live and work (often called looking deeply at the ‘social determinants of health’) but that’s a subject of another article perhaps.
We tend to deal with health care after illness strikes instead of addressing the root causes of illness, or as we said at the outset, look ‘upstream’ for the underlying causes. In other words, as John McKinlay described at the beginning of this article, we should do our best to avoid short-term, problem-specific, and individual-based interventions and instead think of wider populations and how we can get them to pursue good preventive actions and wellness-focused actions instead. Today, approximately 95% of the money we spend on health in the US goes to direct medical care services-commonly called ‘sick-care’, with only about 5% allocated to public health activities and population-wide approaches to health preservation or wellness side actions. This certainly seems unbalanced when you realize that most early deaths and chronic illnesses are attributable to behavioral patterns, environment, and social circumstances. In fact, ‘poor diet’ and ‘physical inactivity’ are the two greatest contributors to the world’s biggest and most silent killer -hypertension, as we have described in detail here. We have it in our hands to make this transition will a little help or ‘nudging’.
Jon Warner is CEO of Silver Moonshots-www.SilverMoonshots.org, a research and support organization for enterprises interested in the 50+ older adult markets with its own aging-focused virtual accelerator. He is also Chapter Ambassador for Aging 2.0 and Advisory Board Chair for several Health startup organizations in the Health and Healthcare space). Jon is based in Greater Los Angeles, California.