Contagious Conversations / Episode 46. Hypertension: Handling the Pressure
Transcript
Dr. Judy Monroe: Hello and welcome to Contagious Conversations. I'm Dr. Judy Monroe, President and CEO of the CDC Foundation and host of today's conversation. Every episode we hear from inspiring leaders and innovators who make the world healthier and safer for all of us. Contagious Conversations is brought to you by the CDC Foundation, an independent nonprofit that builds partnerships to help the Centers for Disease Control and Prevention save and improve more lives. Joining me today are Dr. Jerome Adams and Dr. Ezekiel Emanuel. Dr. Adams is executive director of Purdue University's Health Equity Initiatives, and Dr. Emanuel is Vice Provost for Global Initiatives and the Levy University Professor at the University of Pennsylvania.
As the 20th U.S. Surgeon General and a prior member of the President's Coronavirus Task Force, Dr. Adams has been at the forefront of America's most pressing health challenges. Dr. Emanuel served previously as Special Advisor for Health Policy to the Director of the Office of Management and Budget in the White House, and also served as chair of the Department of Bioethics at the National Institutes of Health. In this episode, we discuss the health risks posed by hypertension, reasons why it is so prevalent in the United States and the steps we can all take to stay healthy. So, welcome to you both.
Dr. Ezekiel Emanuel: Great to be here.
Dr. Jerome Adams: Thanks so much for having us.
Dr. Judy Monroe: Nearly half of all U.S. adults have hypertension, but only one in four of those individuals have their hypertension under control. Dr. Emanuel, I'm going to start with you. Why is hypertension so prevalent in our society?
Dr. Ezekiel Emanuel: Well, it is a serious problem. We have about 110 million adults who have hypertension. It's an enormous, enormous problem and it baffles the mind, given the fact that we have, now, cheap blood pressure cuffs where people can take their blood pressure at home, great ones under $100, some even under $50. We've known it's been a serious problem and what to do about it. But there are four or five big, big issues, and they're the same big issues that affect every other part of healthcare. You know, let's start with exercise. Not enough Americans engage in exercise. We have more than 60% of adults not engaging in 150 minutes a week of exercise. And when I talk about exercise, you don't have to be training for a marathon, or, like me, going out and bicycling like a maniac. Briskly walking around the block will do. Getting your heart rate up is the key here, and we don't do it.
The second is diet. We have a situation where too many Americans eat processed foods, and those processed foods, we know, if you look at the list of ingredients, have way too much salt. And high sodium content, low potassium content is another major, major problem for Americans. Third on the list, of course related to the first two, is obesity. 40 percent of U.S. adults are obese. Obese people have higher blood pressure, and that is a serious problem as well. Exercise, diet and obesity are all mixed together. And by the way, they're not just big risk factors for hypertension. They're big risk factors for heart disease. They're big risk factors for cancer, for Alzheimer's disease. So, you really want to get control of them. And the last one, I would say not the last in the long list, but alcohol consumption drives up hypertension. I think that's one of those factors that not very many people know. We have a lot of people in America, also probably not well-known, who are teetotalers and don't drink, but we have a number of people who drink and drink excessively, whether it's binge-drinking, too many drinks a day. That combination of four things is a bad risk for causing hypertension.
Dr. Jerome Adams: Dr. Monroe, I want to say I completely agree with Dr. Emanuel, but I also want to highlight something that I think we miss far too often. When you look at the causes of hypertension–and it's not just hypertension–we've seen hypertension control decrease. So, even amongst the people who know that they have it. It's kind of like the care continuum that you think of for HIV. You first got to diagnose, then you've got to get people connected to care, then you've got to get people treated, then you actually want to get people under control.
A significant number of people don't have it under control, even if they are in treatment. But Dr. Emanuel mentioned exercise. Well, it's one thing to know that we aren't exercising as much as we should, it's another thing to acknowledge that people don't always live in communities or in situations where it's easy to exercise. For many people, they may not have safe environments to exercise. They may not have complete streets. Uh, diet. We know that far too many folks can't afford nutritious foods and healthy foods or can't access healthy foods. I was in a community just yesterday that I was driving through, and I saw three different liquor stores, I saw multiple tobacco shops, I saw several convenience stores, but I didn't see a single grocery store.
And thinking back to all of us when we were in medical school, we got lots of instruction on which pills to prescribe to people, but very little instruction on how to counsel people to engage in healthier eating. And that leads, as Dr. Emanuel said, to obesity. But even in the doctor's office today, I feel like we're scared to tell patients that they are obese. We've normalized higher weights. That, I think, is a real challenge. We need to tell people obesity is a risk factor for a lot of bad things and a lot of us are overweight or obese.
And then finally, the normalization of alcohol. This is, again, something that's cultural. I mentioned I saw more liquor stores than when I saw grocery stores in the community that I was in. We love our football and every other commercial on TV is an alcohol commercial, normalizing it and telling us that everything's going to be great. We're going to have a great time. We're going to get that partner that we want if only we drink one more Bud Light. And I think it's important that we think about the culture and societal aspects that make it hard for us to have good control over hypertension.
Dr. Judy Monroe: Yeah, those are really important points. And talking about preventing hypertension, I mean, you've just laid out all these barriers to living those healthy lifestyles. The other thing I wanted to dig in, we see these shocking figures about hypertension. But we also know that within the Black community, hypertension rates are even higher. More than three quarters of Black adults will have hypertension by age 55. What steps can we take to address this imbalance from an equity standpoint?
Dr. Jerome Adams: Well, I'm so glad you brought that up. Among Black adults, 41.5% had their blood pressure controlled compared with 48.2% of White adults in the years 2015 to 2018. And when taking anti-hypertensive medication, 55% of Black adults had their BP controlled compared to 60% of Asian Americans and almost 70% of White adults. So we're seeing some incredible racial and ethnic inequities. And this steamrolls into the sequelae of uncontrolled hypertension. It steamrolls into kidney disease and cardiovascular disease, strokes and heart attacks. And you ask, what are the challenges? Well, we know they're a myriad. We know it's harder for certain populations to get their hypertension diagnosed. Once it's diagnosed, we know it's harder for them to actually get treatment. We know the insurance rate is much lower for people of color, and so that limits their ability to access healthcare providers and to actually get their medications, and to continue to adhere to their medication. So, medication adherence is a big deal.
But as I mentioned, those social drivers of health are also far more prevalent in the African-American community. It's harder for them to eat right. It's harder for them to exercise. And one final point that I want to hit on, because I don't feel like we do a service to this discussion, that's the idea of weathering and of systemic racism. We often talk about it from a moral perspective, but I think we need to talk about it more from a scientific and a health perspective. We know that when you're constantly facing microaggression, when you're constantly facing stress, that causes a surge in your catecholamines. That causes an increase in cortisol. And we know scientifically that there are mechanisms that cause higher rates of blood pressure in Black and Brown communities because of the constant societal challenges that they face, including racism and bias.
Dr. Ezekiel Emanuel: I want to emphasize one thing that Jerome said, which is we have huge inequities when it comes to hypertension. And if we actually addressed hypertension, substantial health inequities ... I'm not talking about healthcare and insurance and access, but just substantial health inequities ... outcomes would be different because hypertension sits at this nexus of heart disease, kidney disease, cardio-cerebrovascular disease and strokes. And if you can actually get hypertension under control, all of those, which have very large racial disparities, become much less important and the mortality associated with them goes down. We've known this since the ‘60s. So, one of the best ways of getting to health disparities and really addressing it is focusing on hypertension, not focusing at the end on heart attacks or dialysis. That's way too late. Way too late.
The other thing I want to bring up is our inability to address this problem. The fact that depending upon your number, it's certainly less than 50% of Americans are well-controlled, and that's not for lack of information or therapeutics. We know about, as we said, better diet, exercise, sodium, alcohol, stress. But beyond that, we have a guideline which is widely agreed. The American Heart Association, the American College of Cardiology, every group has agreed on a uniform guideline. We have scores, actually hundreds of medications, for hypertension, almost all of which are generic. And yet we do so miserably bad.
One of the things I think is critical is doctors have to take this seriously. Not that they should manage it, but that their practices manage it. I don't think this is probably best managed by physicians. Ultimately, they have to write the prescription. But this is the kind of chronic illness where you need a care coordinator who's proactively reaching out to the patients on a regular basis until taking their blood pressure and taking their medications becomes a habit. That takes 60 to 90 days as we know, you got to put it at some place in the day. You've got to be sort of religious about it. And once it's part of your routine, it'll stay part of your routine because we don't like to change our routines very much.
And that is not something doctors are going to do. Doctors can say to the patient, ‘This is really important.’ Doctors can introduce the care coordinator. But ultimately, it has to be a coach and care coordinator who is going to take the patient through getting a little more exercise every day, eating less sodium every day, less prepared foods, a few more fruits and vegetables, and really begin them on that path towards getting their blood pressure under control and educating them why it's actually really, really important.
Dr. Jerome Adams: I want to ask Dr. Emanuel a follow-up question because I put out a call to action on hypertension control when I was Surgeon General in 2020, and many people thought that was an odd time to put out a call to action because as you remember, we were in the middle of a pandemic. But I will remind folks that in 2020 and 2021 and 2022, and every year that we've gone through this pandemic, we've lost more people to uncontrolled hypertension than we've lost to COVID-19. So, I agree completely we need to make hypertension control a national priority, which is one of the three goals of my Surgeon General's Call to Action. Make it a national priority, including making sure healthcare systems make it a priority.
Number two, as Dr. Emanuel mentioned, we need to ensure the places where people live, learn, work and play support hypertension control. That's the community aspect. But then number three, we need to optimize patient care for hypertension control. And couldn't agree more, doctors need to be part of this, but you can't put it all on the doctor. You need to understand that it's going to take nurse practitioners, it's going to take pharmacists, it's going to take community health workers all coming together. At my hospital, I actually was chair of the Pharmacy and Therapeutics Committee and helped oversee collaborative practice agreements with pharmacists to improve medication adherence and making sure people were on the right medications.
When you talk about the African-American community, far too many doctors and healthcare providers aren't aware that the best medications for people of color aren't the same medications you would start someone on if they were Caucasian. But my question for Dr. Emanuel ... I mean, you advised the White House, you advised OMB (the Office of Management and Budget), and we know that ultimately a lot of this comes down ... W. Edwards Deming famously said, ‘Every system is perfectly designed to get exactly the results that it's getting.’ And so we're getting terrible hypertension control. Well, that's because the system is set up for us to get terrible hypertension control. How do we make hypertension control a national priority using funding levers, Dr. Emanuel? Because we know that ultimately, what doctors and healthcare systems do are what CMS (Centers for Medicare and Medicaid Services) and payers reimburse them to do.
Dr. Ezekiel Emanuel: Well, I think that there are multiple answers to that, and I think you're 100% right. It's important to have the Surgeon General say that's a top priority, but it's also important for CMS, for the Defense Department, for the Federal Employee Health Benefits Program to make this a top priority. And how do you make it a top priority? Well, just take what things CMS can do. CMS could make it hypertension control and the percent of people with hypertension and under control following their guidelines, maybe giving them a blood pressure cuff. They could make that a top quality metric. They could also, I think, reimburse for this in a different way, and I think that would be very, very important. I will say they could also produce data in local areas, metropolitan statistical areas, on which practices are doing better in hypertension control, and actually name them. We know performance feedback works and comparative performance feedback works.
Finally, one of the things I'm most encouraged by is the California Exchange. Covered California has decided it's getting rid of all these myriad quality this-and-that to evaluate plans, and it's focusing on four things. And one of those four things is hypertension control because they've realized how important it is to their communities. And again, if you've got hypertension under control, you affect all these other things, whether it's kidney disease, cardiovascular disease and cerebrovascular disease. Absolutely critical for improving the quality of life and longevity of people. And then if you also get them to do lifestyle changes, it affects so many more things, Alzheimer's and cancers, as I've mentioned. So, I think making it a quality metric and focusing, giving physician practices feedback, MA (Medicare Advantage) plans focus on it as well and then changing the reimbursement.
The thing that I find is we have so many bad health outcomes, hypertension being at the top. We have diabetes, also, where we're not doing so hotsy-totsy, again, even though it's not complicated. We have this tendency to, ‘We've got to have a lot of priorities.’ That, I think, is one of our big mistakes. I learned from my brother, the politician, you want to focus people on just one or two things and really get everyone focused. And the reason I think hypertension control is we know over the last 60 years, the single biggest impact we've had on life extension, positive impact, has been by controlling blood pressure in the ‘60s through those old thiazides and diuretics. And we could have a very, very big impact on life expectancy, longevity and disparities in healthcare. There are so many goals that this hits and so many health outcomes if we got blood pressure under control that it would make a huge difference to the system, and so I think prioritizing hypertension. I know we've got 37 million diabetics, but we have 110 million people with high blood pressure, and that's our biggest, biggest national concern.
Dr. Judy Monroe: Yeah, you're really making a compelling case here and prioritizing. Narrowing down the number of priorities makes perfect sense. We'll be right back with Dr. Jerome Adams and Dr. Ezekiel Emanuel.
According to CDC, high blood pressure increases the risk for heart disease and stroke, two leading causes of death for Americans. High blood pressure is also very common. Tens of millions of adults in the United States have high blood pressure and many do not have it under control. Learn more facts about high blood pressure at cdc.gov/bloodpressure.
And now, back to our conversation with Dr. Adams and Dr. Emanuel.
And then looking at the lifecycle, I wanted to come back to maternal mortality and morbidity. We know that hypertension plays a big role there. Dr. Emanuel, can you talk to us a bit about the impacts of hypertension on the health during pregnancy?
Dr. Ezekiel Emanuel: Well, one of the terrible tragedies in the United States, real tragedies, we don't have a lot of maternal mortality in the sense of we're talking under 2,000 cases a year. But that has huge ramifications on families, huge ramifications on children, of the mother. Just a total, total disaster. And we're so far out of the norm compared to European countries and other high-income countries. A major cause is preeclampsia, postpartum-hypertension and hypertension. It's not the only one. The other big one is hemorrhage that we are bad at identifying as an emergency and controlling. But absolutely, hypertension around pregnancy is a huge problem.
I will just say one of the things I'm really proud of, and I had nothing to do with this, I can just be proud like a parent, is one of our groups is like, ‘We are not going to have mothers who just gave birth, who have high postpartum blood pressure or are at risk for it, come back every day to get their blood pressure measured at the hospital. That's just not feasible.’ So they sent them home with a blood pressure cuff and they pinged them, texted them, to take their blood pressure and get it back. Dramatically increased. Now, it still wasn't 90% that you would like and were taking their blood pressure, but it was a dramatic improvement. And then, they could monitor and those mothers who were too high, they could get them treatment, either bring them in or send a nurse practitioner out. That's the way we have to do it. And again, I think given the cost of blood pressure cuffs commercially. That's not buying it in bulk and all of the things that could drive the price down.
Dr. Jerome Adams: And Dr. Monroe, as you know, I put out a call to action also on maternal health in 2020. The American Heart Association has really emphasized that link that you mentioned between maternal mortality and uncontrolled blood pressure. But it's not just about maternal mortality. As Dr. Emanuel laid out, one of the challenges is that as tragic as these cases are, it is a small number of the overall population who's actually dying, mortality. But what we don't, I think, focus enough on is also the maternal morbidity. And we know that if you are diagnosed with hypertension while pregnant, and your hypertension is not controlled while you're pregnant, you are much more likely to have hypertension throughout the rest of your life and to go on to have stroke, kidney disease, heart disease and the like.
And so it's a critical touch point, and it's a point that if we fail to intervene, we know that we're setting that mother up, that woman up for trouble for the rest of her life, even if she's not one of the unfortunate people who actually dies. So, I think it's the canary in the coal line, if you will, when we look at maternal mortality. And because of maternal morbidity, there are exponentially more women out there who we could intervene on their behalf and actually prevent them from having problems later in life. And again, that's why you see the American Heart Association focusing on this.
Dr. Judy Monroe: So Dr. Adams, I want to stay with you on that. On seeing these rates of hypertension continue to climb, you're a great communicator. How do we communicate better to drive this as a national priority? Because we do need to get policymakers on board and align CMS, as you all have talked about. There's so much alignment that could take place to really move the needle on this.
Dr. Jerome Adams: Well, it's a great question, and one of the other projects that I've worked on with you, Dr. Monroe, was my Community Health and Economic Prosperity Report, making the case that America's poor health is hurting our economy. It's hurting our workforce. It's driving up healthcare costs. We pay two-and-a-half times as much as any other OECD nation (Organization for Economic Co-Operation and Development) for healthcare, yet we continue to get terrible results. And a lot of that cost is born by our businesses. And so we need employers to really understand how uncontrolled hypertension is impacting their bottom line. But we also, as Dr. Emanuel has pointed out, need to help them understand that there are simple interventions that can really help us lean in and change the dynamic.
Home blood pressure monitoring, but also making sure you've got opportunities for people to check their blood pressure at work. Employers can also say, ‘We want this to be a marker of our insurance plans,’ in terms of a quality metric. They can make it a priority, making sure the medications that are going to be best suited to control hypertension are covered by your insurance plan, and making sure you're holding providers accountable for following treatment guidelines. These are all ways employers can lean in. But when we talk about community drivers of health, employers can make sure they have healthy and affordable food options in their cafeteria and that people have time off both from a mental health and a physical health perspective to attend to their health. I actually am advising a major government agency right now, and one of the things that they are incorporating into their health improvement plan is giving people time off from work during the day to take a mental health break, to go out for a walk, to go to the gym at work.
There are lots of things that we can do working with employers to improve hypertension control. But Dr. Emanuel mentioned something earlier that I think has real potential. In my report, I talk about emphasizing and leveraging electronic health records to help identify who is at highest risk and to help guide providers towards making sure they're delivering guideline-based care. Well, with AI, as Dr. Emanuel mentioned, we have a tremendous opportunity to really improve care by helping providers and health systems identify who's at risk, again, make sure they're getting the best care, but also give feedback to providers, that comparative performance feedback that Dr. Emanuel discussed. AI can really help us move the ball down the field on this seemingly intractable problem by leveraging the data that's available to help us deliver better care.
Dr. Judy Monroe: That's really exciting. I see AI as having incredible promise.
Dr. Ezekiel Emanuel: One thing that worries me a little bit is the interest of insurers and employers in tackling hypertension. One of the challenges is that treating hypertension today and investing in it doesn't typically pay out in the next 12 months. It's a long-term problem.
Dr. Judy Monroe: Right.
Dr. Ezekiel Emanuel: Chronic disease. And one of the problems employers and insurers have is making investments that's over more than a one-year time horizon, and I think that's a serious problem. The consequence, in my opinion, is that you can only get them to focus on it where ‘them’ is enough of them. Not one or two enlightened ones, but many of them–50%, 60%, 70% of them–by making it a requirement one way or another. A requirement for the commercial insurers, a requirement for the MA plans, because I'm just worried that as much as it should be in their interest, their financial incentives are not to invest in the long-term health of their workers.
And I would just say if you look at what employers are saying today, the top number one issue for them is cost control, and that almost always translates into, ‘We're going to reduce our investment for the long-term.’ The number two issue, importantly, is mental health and maybe reducing some of the stress that Jerome mentioned. But I just worry that left to their own devices, this will not rise to the urgent need it needs to and, therefore, I am inclined to think of a government intervention in mandating this being a quality requirement, et cetera. And holding those commercial insurance companies and the employers responsible is going to be a very important key to success and actually getting this at the top of our agenda.
Dr. Judy Monroe: Well, it makes a lot of sense, and you both have given a really compelling case for why this should be a priority. I like to end on a positive note. I ask both of you, what are we doing right in combating hypertension and where are we having successes?
Dr. Jerome Adams: And I'm so glad that you brought us around to this point because in my Hypertension Control Call to Action, we certainly lay out the challenges, the real challenges we face from a racial and ethnic disparity perspective and from the perspective of the fact that control is going in the wrong direction, but we also raise up best practices. There are many Native American tribes that have leaned into hypertension control in some of the most austere locations, places where it is harder to eat healthy, where it's harder to exercise, where it's harder to get access to medications. And they've proven in the Phoenix Indian Medical Center, for instance, that they can drive down hypertension rates and increase hypertension control rates through concerted action.
And that's what gives me hope is that we know that even in some of the most difficult populations and situations, we have examples of success if we just make it a priority. That is the most important thing. We need to make it a priority for employers, for businesses, for governments, for communities. And if we do that, then it becomes easy because we have the guidelines. We have the medications. We need to do a lot more, quite frankly, to provide community support. But I'm heartened because of the fact that we've seen success, that we have more and more people appreciating the importance of social drivers of health, particularly on the heels of the pandemic, and that we have more technology through automated blood pressure devices that we can send people home with, and through electronic health records and through AI.
So, the time has never been better to make this issue a priority. And I think if we do that, then I think we can see some success. And if we see success in hypertension control, for all the reasons we've mentioned thus far, we will actually see improvement in maternal mortality, in cancer, in diabetes, in stroke and kidney disease and heart disease, and many of these other areas where we know this is a predictor and an exacerbator of downstream problems.
Dr. Judy Monroe: Ezekiel, over to you.
Dr. Ezekiel Emanuel: Yeah. So, I think it's important to look at places that have done an excellent job and look at the kinds of things that they've done because we know these are not intractable problems. And we know that there are groups and municipalities that have done a fantastic job. And I think Dr. Adams has said a key word: concerted effort. It can't just be a one-off. But if a physician practice makes a concerted effort, they can get to 70%, 80%, 90% of blood pressure control way better, at least double what we have today. Similarly, we know that Minneapolis, a number of years ago, was able to make a major effort in the Minnesota area by getting practices to report their results in terms of hypertension, producing those reports so everyone could see how well they were doing and how well they were doing comparatively, getting them to adopt the guidelines and implement them.
That didn't happen overnight. It took four or five years, but they got to, if I recall correctly, something like 70%-plus hypertension control. Practices is just one area. You also need the public health departments in cities and states to put this top. And you need CMS, again, to put it top of their list for quality metrics that they hold insurers accountable. But the concerted effort and looking at groups that have achieved very high rates of blood pressure control, I think, is going to be the key to making progress. And then, again, to have a sober timeline that it's not going to happen in one year. It's not going to happen in two years. It's going to take four or five years, but the payoff is going to be huge to the health and the health disparities in this country.
Dr. Judy Monroe: Well, thank you both for joining me today. This has been a terrific conversation and I'm feeling like taking action, so let's move on this.
Dr. Jerome Adams: Well, that's certainly what I hope. I hope people will take action because hypertension control is possible. And I would advise folks to check out my call to action at surgeongeneral.gov because we know that this can be done. So thanks for hosting us today, Dr. Monroe. Dr. Emanuel, it's always a pleasure chatting with you. It's great to see an oncologist and an anesthesiologist agree on something, and we both agree that this is something that we need to prioritize.
Dr. Ezekiel Emanuel: Yeah. Great to be here. Thank you. And I congratulate and commend the CDC Foundation for putting this as the top priority.
Dr. Judy Monroe: Well, thank you so much. Be healthy.
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