Blood Pressure & Social Judgment
Updated: Dec 30, 2022
Salt may be just an "innocent bystander" in the big picture of hypertension rather than the culprit it has been assumed to be for years.(1) There are larger societal issues that better explain why many people have high blood pressure.
One primary principle of allostasis is how our brain-bodies anticipate and adjust to what is next with maximum efficiency. In this light, we can understand chronic disease as the brain-body doing its very best to adapt to the circumstances, rather than viewing disease as something broken that must be rebalanced as homeostasis dictates.
To understand how this works, meet my patient B, who was referred to me to discuss potential stress and behavioral factors because her essential hypertension was not responding to her now, third, medication (most hypertension is “essential” or unexplained). She had no other risk factors on the typical list: no alcohol, tobacco, or obesity. She was active, ate well, and enjoyed many pleasant activities. At our first visit, she reported little daily stress. She reduced salt intake from little to even less. Her elevated blood pressure remained unfazed.
Blood pressure is meant to vary depending on what our needs are, going higher to meet an anticipated higher demand, and lower to efficiently conserve resources. It does not stay static, but dynamically shifts and adjusts based on what the brain anticipates. It then works to efficiently match the demand required for the next moment, and the next, based on the information available up to the current moment. It is anticipatory more than reactionary.
B’s blood pressure rose up to a new level and eventually stayed there with less fluctuation than healthier blood pressure. But it was still a mystery why B’s blood pressure needed to be that high. What was its function? What was it adapting to? What was it anticipating?
B’s husband, J, came with her to most of her appointments. They dressed nicely, came on time, spoke softly, and supported each other with tender respect. They attended church, planned pleasant outings, and traveled. At our third visit, B said they did experience some stress when they left the house because her husband needed to inject insulin for his diabetes. We explored their concerns about his health, which he was managing quite well.
B noticed her anxiety went up whenever J needed insulin outside their home. She said there was nowhere he could go to inject himself. I asked what she meant – why not in the car or public bathroom? B’s face froze and she looked at J. Because they were African American, they feared that someone might see J using a needle, misinterpret this as drug abuse, and call the police. She feared this event could trigger more severe problems or even death for her husband and herself. This was a chronic worry for both of them, one they had gone to great lengths to hide in order to avoid a more devastating situation with public authorities.
Allostasis, compared to homeostasis, fully acknowledges the context that B was living with rather than viewing her blood pressure as an individual medical problem casually explained as "too much salt" or “likely genetic.” (Research does not support either explanation). Rather than an individual disfunction, allostasis expects to see blood pressure rise and stay high in order to adapt to the increased resources that kept B vigilant in public. A public who viewed her and her husband with less grace than others and put them at a relatively higher risk of harm.
Understanding B’s high blood pressure as an adaptation opened up new treatment options that supported her daily experience. Her goal was to reset her brain-body’s full range of blood pressure to include low, resting blood pressure levels and only have high blood pressure kick in when it was really needed. Her practice was to continue controlling what she could regarding self-care; the challenge was to do it with less fear.
This principle of allostasis, disease is adaptation, allowed us to talk about B’s experience of the world, discrimination she and J faced, and her sense of safety in any given situation. The awareness alone helped B calm her own nervous system, connect with supportive community resources, and brought clarity to the action she and her husband might need to take depending on their physical location.
Essential hypertension is often a symptom of a larger problem, one with important information for our wellbeing as individuals and a society. Medications are often ineffective, come with risks to health and wellbeing, and rarely address the larger issue. B’s story reminds us how our health and wellbeing is intricately related to how we treat one another.
Read a lot more about this here: Peter Sterling’s Chapter 1 Allostasis, Homeostasis, and the Costs of Physiological Adaptation in Jay Schulkin’s Principles of Allostasis.
(1) DiNicolantonio, J. J., Mehta, V., & O'Keefe, J. H. (2017). Is Salt a Culprit or an Innocent Bystander in Hypertension? A Hypothesis Challenging the Ancient Paradigm. The American Journal of Medicine, 130(8), 893–899. https://doi.org/10.1016/j.amjmed.2017.03.011