Transcript Predictive Health

Cardiometabolic Research in the
Center for Health Discovery and
Well Being at Emory University
The Imminent Revolution in Healthcare
Emir Veledar PhD, Arshed Quyyumi MD, Jennifer Vazquez, MS, Lynn Cunningham, MS, MBA,
Kenneth Brigham, MD
Emory University *Division of Cardiology;** Predictive Health Institute
Predictive Health
the concept
The majority of resources
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in both biomedical research and clinical care is
spent on organ and disease focused activities
even though end organ failure is often an
irreversible process.
A third of the Medicare budget is spent in the last
year of life
and a third of that amount is spent in the last
month of life.
Research with this focus results in dramatic but
increasingly expensive interventions that often
have problematic effects on quality of life.
Goal for Health system
to maintain health rather than to treat disease.
 implementing general interventions that
epidemiological evidence indicates will improve
health—“preventive medicine”---in health care
systems.
 New programs of this sort with novel titles are
appearing at major academic institutions.
 shifting emphasis away from end organ failure
and toward health maintenance in the health
care continuum.
 That shift will gather momentum if improved
efficiency and cost/benefit become more
apparent.
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The shift in focus of biomedical research
for biomedical research has been slower to
develop.
 There is a need to focus the formidable power of
the research enterprise basic,
 translational and
 clinical
 on developing a positive definition of health in
quantitative terms and on developing an
evidence base for novel health care paradigms
that promise improved cost effectiveness.
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The shift from disease to health
This would provide essential tools for
 health surveillance,
 risk assessment and
 premorbid diagnosis
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for interventions
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in essentially healthy people
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that would preclude progression to end organ
failure.
Predictive Health
Definition
“Predictive Health anticipates the course of
an individual’s health status, based on
leading edge science and technology, and
prescribes interventions that proactively
optimize wellness”
“This revolutionary approach will move from a
reactive disease focused system to a pro
active health focused system; disease
becomes a medical failure”
The Health/Disease Continuum
Normal
Low risk
H
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L
T
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Normal
High risk
Pre
disease
Early
disease
Late
disease
Predictive Health
Contemporary Medicine
D
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Predictive Health and Public Health
Congruence
Protecting health: The territory
DIABETES
S
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A IR E
IM P COS CE
U
GL ERAN
L
TO
IR
O
NM
EN
T
Determinants
of
Health
INFLAM MATION
OX
IDA
ST R T IVE
ESS
EN
V
BE
HA
VIO
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T IC
NE
GE
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IV
AT L
R
A
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N E NT
GE T E
E
O
R P
IMMUNE
HEALTH
EARL Y
IT IV E
C OGN
N
NCT IO
DYSF U
INCREASED
CAROTID
IMT
DEPR ES SI
ON
Generic Processes
NEURODEGENERATIVE
DISEASE
ATHEROSCLEROSIS
PSYCHIATRIC
DISORDERS
ASY
MP
PRE T O MAT IC
- CAN
C ER
CANCER
Pre-disease
Disease
Role of Academic Health
Centers in the Health Care
Transition
◦ Multiple disciplines within one organization
◦ Creative mindset
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Strong research base
◦ Capacity to foster (and direct) collaborative,
interdisciplinary research on a large scale
◦ Catalyst for translational research – integrated
basic science, healthcare, public health, and
other necessary, supporting disciplines
◦ Objectivity about national economic issues
◦ Organized voice in national debate
Predictive Health: Systemic
Implications
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Education
◦ General public
◦ Politicians
◦ Health care professionals
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Economics
◦ Government
◦ Insurers
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Information technology
The Emory-Georgia Tech
Predictive Health
Institute
Predictive Health Institute Themes
•Define and measure health
•Invent/discover optimal biomarkers of
health
•Identify optimal interventions to optimize
health
•Determine how to apply this new
knowledge to individuals and populations
Determinants of
Health
Environment
Genomics/
Metabolomics/
Proteomics
Genetics
Population
Biology
Behavior
Molecular Imaging
Systems Biology
Generic Pathways
Bioinformatics
Technologies
Nanomedicine
Quantitative
Medicine
Ethics
Disciplines
Immunology
and
Inflammation
Development
Oxidative
and
Stress
Senescence
Public Policy
Finance and
Economics
Other Generic Regeneration
and Repair
Pathways
Novel
Therapeutics
Education
Specific Diseases
Cardiovascular
Diseases
Chronic Lung
Diseases
Cancer
Diabetes
Neurological
Diseases
The Emory Georgia Tech Center for
Health Discovery and Well Being
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A partnership of discovery
◦ Discovering individual health
◦ Expanding knowledge of human health in
general
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A new health care paradigm
◦ Health focused
◦ Merging health care and research
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A grand experiment
◦ Inventing a new health care model
Emory-Georgia Tech Center for Health
Discovery and Well Being
Assessment: The Surveys
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Surveys collect
information about
 Mental, Emotional &
Spiritual health
 Health Symptoms,
Exposure, Behavior &
Physical Activity
 Nutrition, Supplements
& Medications
 Stress, Anxiety,
Depression & Sleep
Patterns
Copyright 2005-2008 Emory University
Assessment: Instrumentation
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Resting Blood Pressure
and Heart Rate
Anthropometrics &
Body Composition
 % body fat
 Lean Body Mass
 Bone Mineral Density
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Copyright 2005-2008 Emory University
Treadmill Fit Testing
Vascular Testing
 Arterial thickness
 Arterial elasticity
 Central Blood
Pressure
Assessment Laboratory Studies
More than 50 different lab tests
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Known biomarkers
 Endocrine Health
 Immune Health
 Metabolic Health
 Inflammation
Health
 Nutrition Status
Copyright 2005-2008 Emory University
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Research
biomarkers
 Oxidation Status
 Inflammation
Status
 Immune Function
 Regenerative
Capacity
Health Assessment Report
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Compilation of results
from assessments
Includes instructions
about how to interpret
Includes comparison
norms (age, gender,
etc.)
Includes general
health education and
resources
Take home tool
Copyright 2005-2008 Emory University
Health Action Planning
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Collaboration with their Predictive Health Partner
Participant empowerment & engagement in goal
setting
What does this mean for the participant
 Work-life balance
 Nutrition
 Physical activity
 Mental and emotional health
 Spiritual health
 Health risk behaviors
Personalized Health Action Plan (internal/external
resources)
Follow up assessments
Role of Predictive Health Partner
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Relationship Builder
 Facilitator
 Consultant
 Educator
 Translator
 Confidant
 Specialist
 Collaborator
 Navigator
Predictive Health
Research
The Cardiometabolic Study
Cardiometabolic Risk Factors and the
Metabolic Syndrome
dyslipidemia,
 insulin resistance,
 elevated blood pressure and
 obesity/overweight
commonly referred to as the metabolic syndrome.
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tend to cluster and clearly confer
 increased risk for the development of
atherosclerosis and consequent cardiovascular
pathology
Coincident with the “epidemic” of
overweight/obesity in the United States
 portending an increase in cardiovascular
morbidity and mortality in the future.
 The syndrome is characterized by increased
biomarkers of inflammation and oxidative stress
even prior to development of cardiovascular
morbidity (Kaya 2009, Dawood 2009).
 Improved diet and regular exercise have been
shown to be effective in reducing various
components of the metabolic syndrome (Ma
2009), but
 public health approaches to effecting such
behavior changes have not prevented its
increasing incidence
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Predictive Health
The Imminent Revolution in Health Care
Study Population
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A random sample of Emory’s 20,000
employees.
Upwards of 300 participants
 completed an initial evaluation and
 have been assigned a Health Partner.
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follow up evaluations at 6 months and one
year following enrollment.
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Drop out less than 2%
Demographics
characteristics of this cohort are similar to
those of the overall Emory employee
population:
 mean age=49+/-10 SD yrs;
 race- 71% white, 23% black, 5% other;
gender- 65% female, 35% male.
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Income distribution covers the range of
employees from <$50K per annum to
>$200K per annum household income.
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Metabolic syndrome criteria
The five criteria (ATPIII) that are generally accepted for
diagnosing the metabolic syndrome are:
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waist circumference >=40 inches in men or >=35 inches
in women;
serum triglycerides >=150 mg/dL or drug treatment for
elevated triglycerides;
HDL-C <40mg/dL in men or <50mg/dL in women or drug
treatment for reduced HDL-C;
systolic blood pressure >= 130 mmHg or diastolic blood
pressure >=85mmHg or drug treatment for hypertension;
and
fasting blood glucose >= 100 mg/dL or drug treatment for
elevated blood glucose.
Figure 1: Percent of study participants to date by numbers of
metabolic syndrome criteria met.
Additional cardiometabolic risk
But that is only a part of the story.
A much larger number of healthy
participants in this program are at
significant cardiometabolic risk.
Figure 2: Frequency distribution (percent of participants to date)
of body mass index (BMI)
Figure 3: Frequency distribution (percent of study participants to
date) of systolic blood pressure (mmHg)
Figure 4: Frequency distribution (percent of study participants to
date) of serum high density lipoproteins (HDL mg/dL).
Figure 5: Frequency distribution (percent of study participants to
date) of fasting blood glucose concentrations (mg/dL)
Figure 6: Frequency distribution (percent of study participants to
date) of serum triglyceride concentrations (mg/dL)
Table 1: Effects of a 6mo Center for Health Disase and Well being
program on variables related to cardiovascular risk (N=51)
Baseline (SD)
Change @ 6mo
(paired mean and SD)
P
88.3(12.9)
-2.1(8.1)
0.04
67.4(19.4)
2.71(8.43)
0.01
4.7(6.6)
2.75(8.05)
0.008
168.4(35.7)
22.6(44.5)
0.007
28.88(10.34)
3.01(6.17)
0.0002
52.1(9.4)
3.88(7.8)
0.05
4.6(5.3)
-1.38(3.77)
0.0045
3.94(3.1)
-1.44(2.87)
0.07
18.0(7.9)
-2.6(6.5)
0.07
47.5(14.2)
10.3(13.3)
<0.0001
118.2(15.1)
-3.6(12.5)
0.02
% body fat
33.8(7.5)
-0.49
0.05
Body mass index
34.5(7.7)
-0.51(2.0)
0.04
variable
Fasting glucose (mg/dl)
HDL (mg/dl)
CD34 count (cells/ul)
Total cysteine
Augmentation index
Mental quality of life (SF36)
Beck depression scale
General anxiety (GAD7)
Perceived stress (PSS)
VO2max
Systolic BP (mmHg)
Pilot data summary
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collected a broad range of health related information and
established a “health profile” for this group.
They are at significant cardiometabolic risk.
They are accessible, recruitable and retention in the
study is high.
Initial analysis show significant improvements in
cardiometabolic variables
As well as other more general measures of health.
To further define the nature and extent of
cardiometabolic risk in this group of essentially healthy
people
Primary outcome variables for this study
will be appropriate directional improvement
in:
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Waist circumference
Serum triglyceride concentration
Serum high density lipoprotein (HDL-C)
concentration
Systolic or diastolic blood pressure
Fasting blood glucose concentration
Measurements of fundamental processes
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Markers of oxidative stress
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Markers of inflammation
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Progenitor cell populations
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Immune markers
Measurements of cardiovascular
structure/function
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Pulsatile arterial tonometry
Arterial Stiffness/Compliance
Additional measures of cardiovascular
structure/function:
 Ultrasound-derived carotid artery intimalmedial thickness
 VO2max (symptom-limited treadmill
exercise test)
 heart rate variability.
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Partner backgrounds:
Minimum of a bachelor’s degree in a health
science or related field. A broad range of
backgrounds and skills are required to
address the integrated complex issues of
health definition and maintenance
including a basic understanding of human
biology. Some background in human
behavior is also desirable.
Training by the professional staff of the Center
will cover the following areas:
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Predictive Health history,
rationale and goals
IRB and informed consent
process
CPR, AED training
Customer relations
Use of instruments and
equipment in the Center
Use and purpose of survey
instruments
Basic physiology, normal
and abnormal test and
survey results
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Empathetic and active
listening
Motivational interviewing
Assessing readiness to
change
Collaborative goal setting
Collaborative decision making
Goal directed problem solving
Elements of coaching,
mentoring, supportive
engagement
The intervention
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Center process
Health assessment and plan
Nutrition
Physical activity
Stress reduction
Personalization of the plan
Other Partner activities
Ongoing contact