Wellness : 5 Normals:The Cleveland · Start &Sustaining the change •Ah Moments—Your RealAge...

Wellness : 5 Normals:The Cleveland

Clinic Experience: Motivating/Sustaining

Change: Improve Health, Save Big $

Dr. Michael Roizen

Chief Wellness Officer

J Gorman & Family Chair,

Wellness Institute

Harvard Physician

40 50 60 70 80 90

Harvard Physician

40 50 60 70 80 90

Harvard Physician

40 50 60 70 80 90

How do you be one of 25%

that do not lose IQ points

as you age?

Start &Sustaining the change

• Ah Moments—Your RealAge & Culture Change

• Environment: physical, work culture that

expects well employees and family

• Social: buddies through, e-coaching, online

programs, social media

• Effective incentive strategy: tied to programs

and “5 normals” outcomes

If YOU Have 5 Normals,

You Are at least 12 Years

Younger (RealAge)

&Lifetime Health Costs Are

33-50% Less

(even last yr costs 50%

5 Normals:

• BP <125/<85

• LDL Cholesterol <130 w/o CV or

<100 with CV

• HgBA1C < 5.7 or Fasting

Glucose <106

• BMI <30 or Waist < ½ Height

• No Cotenine in Urine

If Have 5 Normals, You Are at least

12 Years Younger (RealAge)

&Lifetime Health Costs Are 33-50%

Less (even last yr costs 50% less) • BP <125/<85

• LDL Cholesterol <130 w/o CV or <100 with CV

• HgBA1C < 5.7 or Fasting Glucose <106

With or Without Medications

Better Health Rewards S2243- after

CC Program :Save 200+ Billion A Yr

• Only 4% of Medicare Beneficiaries enter MediCare with 5 Normals

• If have 5 nmls, spend 50-66% of all others lifetime on Medicare (and less on disability), and even 50% less in last yr of life

• Bending Curve would start in 2 yrs; Curve flatten in 5 yrs; Curve Bend Down in 7 yrs

• Each Beneficiary Achieving 5 Normals would get Check reward for doing so

Save $200B A Year By Performance

Testing Gvt Progms

• Bending the Curve Would Start in 2 yrs; Curve Flatten in 5 yrs; Curve Bend Down in 7 yrs

• Each Beneficiary Achieving 5 normals Gets $2000 a Year For Doing So

• Save 1 Trillion in 1st 10 yrs and 2 Trillion plus per 10 yrs thereafter If 75% did so

Projected Health Care Spending in US

1960 1970 1980 1990 2000

Percen

Healthcare Spending in the United States

1960 1970 1980 1990 2000 2009

Percen

& We Lost Our

Manufacturing

Healthcare Spending

$ billions

2007 2009 2011 2013 2015 2017

National expenditures ($)

% of GDP 28%?

Disease Prevalence

Hypertension Heart Diabetes Stroke

US Europe

Prevalence and Treated Prevalence in the United

States and Ten European Countries, 2004 Prevalence a

United States Europe

Percent 95% CI Percent 95% CI US/Europe

difference

Heart disease 21.8 21.1, 22.4 11.4 10.7, 12.0 10.4

High blood pressure 50.0 49.2, 50.9 32.9 32.0, 33.9 17.1

High cholesterol 21.7 20.7, 22.7 19.6 18.9, 20.4 2.1

Stroke/cerebrovascular disease 5.3 4.9, 5.6 3.5 3.1, 3.9 1.8

Diabetes 16.4 15.8, 17.0 10.9 10.3, 11.5 5.5

Chronic lung disease 9.7 9.2, 10.2 5.4 4.9, 5.8 4.3

Asthma 4.4 3.9, 4.8 4.3 3.9, 4.6 0.1

Arthritis 53.8 52.9, 54.6 21.3 20.5, 22.1 32.5

Osteoporosis 5.0 4.4, 5.5 7.8 7.2, 8.3 -2.8

Cancer 12.2 11.6, 12.2 5.4 4.9, 5.9 6.8

Obese 33.1 32.3, 33.9 17.1 16.3, 17.8 16.0

Current smoker 20.9 20.2, 21.7 17.8 17.1, 18.6 3.1

Former smoker 31.7 30.9, 32.5 25.2 24.3, 26.0 6.5

Never smoked 47.3 46.5, 48.2 57.0 56.0, 58.0 9.7

USA HAS TWICE THE DISEASE

PREVALANCE AS EUROPE

Chronic Disease

4 Factors Cause 75%

• Tobacco

• Food Choices & Portion Size

• Physical Inactivity

• Stress

• 81% of hospital admissions

• 91% of all prescriptions

• 76% of physician visits

• Average Cost $6,032/yr

Chronic Disease Impact

Developing Wellness as

Cleveland Clinic’s Fourth Pillar

Patient Care Wellness

Education Research

Employee Wellness Program

ATTEMPTS:

• New Approach: Judge success by health

plan costs – not intermediate variables

• Focus on 4 Biggies:

Tobacco

Food Choices

Physical Activity

Work Stress (Employee Satisfaction)

What was Elvis’s Major

Contribution?

How Much was it Worth

to America?

What was Elvis’s Major

Contribution?

• Immunization on TV, in Papers

• Saved $55B a Year in USA Alone

YOUR Behaviors Are Governed By

•Emotion (not data) for

change

•Environment/Culture for

sustaining change

Control The Controlables

Focus on 4 Biggies:

• Tobacco

• Food Choices

• Physical Activity

• Work Stress (Employee Satisfaction)

GET ALL TOXINS OUT OF

ENVIRONMENT

Smoking Survival

Non-Smoker

Smoker

40 50 70 100 60 80

2005 2006 2007

Smokers Survival 100

% alive

0 40 55 70 85 100

Never smoked

regularly

Continuing smokers

Former smokers,

stopped <35

Data Fr/ CDC & Center for Health Prevention Research at Case Western Reserve University

Cigarette Use Decline?

20.8 20.5

22.3 22.4 23.1

2003 2004 2005 2006 2007 2008 2009

Percen

Cuyahoga

OHIO WITHOUT

CUYAHOGA

FOCUS ON 4 BIGGIES:

• Tobacco

• Food Choices

• Physical Activity

• Work Stress (Employee Satisfaction)

Patient Food Choices and Education

Vending Machines

Cafeterias and Vendors

Store Labels and Farmers’ Market

36 Schauer - “Multibillion Dollar Emerging Market”

• Gradually and

Progressively

increase quality of

foods –

• Great taste and

Great for you!

• Costs no more to

eat for WELLth

Curves Membership

Fitness Center

Yoga Classes

All Cleveland Clinic Facilities Fitness Center Visits

Weight Management

• Weight Watchers

• Curves

• Shape Up & Go

• Fitness Centers

• Yoga

• Farmer’s Markets

• Vending Machines

• GO! Foods

279,000 LBS Lost

January 13th, 2012 l 46

Control

Imagery

1 2 3 4 5

Benefits of Guided Imagery for

Cardiac Surgery Patients

Tusek, Dr Cosgrove et al, J. Cardiovasc. Manag. 1999; 10:22-28

Anxiety

1 2 3 4 5 Base PreOp 0

7.5 days

5.5 days

Length of Stay Post surgery

Cleveland Clinic has done landmark work

on importance of stress management

Stress – The Interheart Study 30,000 patients in 52 countries

Yusef, S. et al., Lancet, 2004 364: 937-952

Smoking Stress Diabetes Hypertension Obesity

k Acute MI Risk

“Psychological distress is comparable to smoking and more significant than

blood pressure, obesity, and diabetes”.

% Increase in Health Care Cost

due to preventable risk factors

Goetzel, J Occup Environ Med. 1998 Oct;40(10):843-54.

Risk Factor (% number of cases)

0% 20% 40% 60% 80%

Depression (2.2%)

High stress* (18.5%)

High blood glucose (4.9%)

Extreme high or low weight (20%)

Former tobacco user (31.1%)

Current tobacco user (19.1%)

High blood pressure (4%)

Poor exercise habits (32.4%)

High cholesterol (18.8%)

% Increase in Health Care Cost (adjusted)

46,000 state and corporate employees. Health care cost estimate

performed for up to 3 years after an initial health risk assessment.

*High stress: Almost always troubled by

stressed and did not handle stress well

• Aims:

- Evaluate program effectiveness (stress, burnout, well-being, productivity)

- Assess if group support improves effectiveness and engagement

• Corporate Call Center (credit card services, debt collectors)

• 160 participants randomized into 4 groups

• Data from 103 (70%) participants at week 8 and 80 (55%) at week 16

Study Design Corporate Call Center

Stress Free Now +

Group support +

4 Expert Led class

Week 1 8 16

Stress Free Now

Stress Free Now +

Group support

Control

Group1

Group2

Very High

Average

Perceived Stress Scale Measure of how unpredictable, uncontrollable, and overloaded respondents find their lives

p<0.05

p<0.01

p<0.001

* ** ***

CTL SFN SFN+Grp1 SFN+Grp2

* *** *** *** * *** *** ***

~40% decrease from very high to average level of stress

Maintained 2 months after end of intervention

0 0 0 0 8 8 8 8

Δ8 16 16 16 16

SF36 – Vitality

80.0 *** **

*** ***

*** **

59% 39%

74% 39%

0 8 16 Δ8 Δ16 0 8 16 Δ8 Δ16 0 8 16 Δ8 Δ16 0 8 16 Δ8 Δ16

Healthy Population

Normative values

lity s

• ~40-70% increase in vitality

• Sustained at 2 months follow-up

CCHS Healthy Choice

• 9% Premium Increase

• Rebate Increase for Personal Responsibility

5 normals = BP, LDL Chol; HgbA1C; BMI,

Cotenine

• Benchmark 12%;Gold Std = 15%

• 1st 6 mos CC = 35%; Upped to 21% Prem:

now >60% of those w/chronic dis & >80% of

others

Comprehensive Approach to a Culture of Wellness

July 2005

January 2007

February 2007

June 2007

September 2007

May 2008

July 2008

August 2008

October 2008

November 2008 May 2009

March 2009 September 2009

October 2009

January 2010

Smash the Ash All Cleveland Clinic

Campuses Smoke Free

Free Smoking Cessation Services offered to all

Cuyahoga County Residents for 6 months

Banned Trans - Fats

From all public and patient menus

Established Wellness Institute and Michael F. Roizen MD

as the Country ’ s

FIRST Chief Wellness

Officer

Stopped Hiring

Smokers

Free Yoga Classes for Employees

Launched weekly

Farmer ’ s Market

for employees and Community

Began free first - dollar Weight Watchers services for EHP

member employees

Welcomed first class of

Lifestyle 180 participants,

teaching healthy choices for patients

with chronic conditions such as

high blood pressure, diabetes, and heart

disease

Initiated free memberships to Curves and Cleveland Clinic -

owned fitness centers for EHP member employees

Shape Up & Go Ongoing team -

based employee walking & fitness

competition

Launched Health Tip of the Day

Launched 360 - 5.com

Launched StressFreeNow

Program

Re - branded and launched Lifestyle EAP

March 2010

Launched

GO!Foods for You

Program

Linked health plan

contribution to

wellness program

participation

July 2010

Removed

SUGAR drinks

from all vending

& cafeterias

Implemented

employee

biometric

collection (ROI

over next 3

years)

Opened 360-5

Retail Store

Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

2007 2008 2009 2010

Employee Health Costs:

Flattening the Cost Curve…

Start &Sustaining the change

• Ah Moments—Your RealAge & Culture Change

• Environment: physical, work culture that

expects well employees and family

• Social: buddies through, e-coaching, online

programs, social media

• Effective incentive strategy: tied to programs

and “5 normals” outcomes

5 Normals:

• BP <125/<85

• LDL Cholesterol <130 w/o CV or

<100 with CV

• HgBA1C < 5.7 or Fasting

Glucose <106

If YOU Have 5 Normals,

You Get A Check

For $2000.00

If Have 5 Normals Get a

$2000.00 Check Each Yr: • Changes The Conversation

Between Patient & Primary Care

• What Can I Do To Get

5 Normals?

Enforcer e-Coaching Process

Client View

Provider View

Patient begins daily

email encounters

Automated / Human

system generates

appropriate

responses

Outcomes: Change in Employee

Variables That Matter

& Changes in Costs & Productivity

• Cleveland Clinic Employee HC Costs (in

Current $) Stable or Dec for 14+ quarters

• CC Employees have lost 279,000+ pnds;

self reported to docs cig use dec from 15.4

to 6.8%; slower inc Type2Diabetes; lower

BP’s; Inc Engagement by 33%

Save $200B A Year By Performance

Testing Gvt Progms

• Bending the Curve Would Start in 2 yrs; Curve Flatten in 5 yrs; Curve Bend Down in 7 yrs

• Each Beneficiary Achieving 5 normals Gets $2000 a Year For Doing So

• Save 1 Trillion in 1st 10 yrs and 2 Trillion plus per 10 yrs thereafter If 75% did so

Health Choices You Make

Determine If USA Will Compete

For Jobs

• Turning Point, But Reversible for You & for Society

• 4 Factors Determine 75% of Costs-Deficit Determined by Your Lifestyle Choices

• Emotion ,Environment (not data),

Social Groups; large incentives

Determines/Sustains Choices

You Can Manage (& Reverse)

Chronic Disease—U Can Vote

(& help many make their RealAges

Younger):

• Go to TedMed.com; Click on

Great Challenges

• Vote for #8

• Make Getting 5 Normals a Ntl

Priority

DISCLOSURE OF INTERESTS:

WWW.RealAge.com

www.youdocs.com

WWW.RealAge.co

Heathradio.net & &

30+ Terrestrial

stations 5-7 PM

YouBeauty.com

Health Choices You Make

Determine If XXX Will Compete

For Jobs

• Turning Point, But Reversible for You & for Society

• 4 Factors Determine 75% of Costs-Deficit Determined by Your Lifestyle Choices

• Emotion & Environment (not data)

Determines Choices

• Know You Control What

Goes In Your Body—and

It Is That Important!!!

• You Can Get A Do Over

WHAT IS MOST IMPORTANT

ROIZEN RULE 4 A YOUNGER RealAge

Causes of Death

0 20 40 60 80

Vaccine Preventable

Colorectal Cancer

Breast Cancer

Suicide

Prostate Cancer

Parkinson's

# Thousands

Vaccine preventable death

kills more then many others

1. Know You Control What

Goes In Your Body—and

It Is That Important!!!

“Avoid Three Food

Felons”

WHAT IS MOST IMPORTANT ROIZEN RULE FOR YOUNGER YOU

For Your Brain

1.Avoid 3 Food Felons That Rob

Your Energy & Your Memory

• Added Sugars

• Simple Carbs (enriched flour)

• Added Syrups (corn, and

others)

FOOD IS NOT

“LETS MAKE A

DEAL”

1.Avoid 3 Food Felons That Rob

Your Energy & Your Memory

• Added Sugars, Syrups, simple

• Blood sugar less than 110 for

heart; less than 250 mg/dL for

We Have A Program

For YOU 4 That—

Teaches Great

Tasting Food Even

a Doc Can Make–

“GO! Foods For You”

Early Atherosclerosis Present in

Virtually All Teenage Americans

• Prevalence and extent of

atherosclerosis in adolescents and

young adults: Implications for

prevention from the Pathobiological

Determinants of Atherosclerosis in

Youth Study.

Strong, JP et al., JAMA 1999 Feb 24; 281:727-35

2. Walk 10,000 steps

MOST IMPORTANT THINGS TO DO

For Your Brain

We Have A Program

For YOU 4 That–

“ShapeUp&Go.org”

1. KNOW YOU Control

What Goes In Your

Body—Avoid Worst 3

Food Felons

2. Walk 10,000 Steps a day

3. Call A Buddy

For Your Brain

We Have A Program

For YOU 4 That–

“Enforcer e-

Coaching” www.YOUDOCs.com

1. KNOW YOU Control

What Goes In Your

Body—Avoid Worst 3

Food Felons

3. Call A Buddy

For Your Brain

4. Add Some Fun Foods

Coffee– 6 cups/day

Chocolate– ½ oz

twice a day

Yellow mustard(turmeric)

Walnuts

For Your Brain

4. Add Some Fun Foods

To Clean Up Brain Poop

Yellow mustard(turmeric)

Activates Apo E = Waist

Mgmt Truck For Your

Brain Like Bexarotene

For Your Brain

5. Avoid Known Toxins

Tobacco,

Including 2nd Hand

Mercury

For Your Brain

6. Do Minimum Physical Activity

For Maximum Health (& Brain)

Benefit

• General = 100 min a day of

movement 10,000 Steps A Day

• Resistance Exercise = 30 min a

• Cardio = 21 min Three X a week

at 80% of max HR

Step 6: Move Your Body Best documented for younger

memory

Increase in

Size of

Hippocampus

with 3

Months of

Aerobic

Exercise

7. Manage Your Stress

For Your Brain

Greatest Stress

Reducers

• Friends, Friends, Friends

• Purpose in Life

• Meditation

• Refocusing & Physical Activity

We Have A Program

For YOU 4 That–

“Stress Free Now”

Solon Call Center – PSS Data • Pilot Study (12 control / 12 StressFreeNow + group meeting)

• Study group too small to draw any definite conclusion from the data

• ~50% stick to the program and were extremely positive about it

Very High

SFN CTL

Average

Call Center –

Kansas City

N=16 N=5 N=9

p=0.002

Weight Change at Week 16

Limitations:

Exploratory

Not all participants were overweight

We Have A Program

For YOU 4 That–

“Stress Free Now”

1. KNOW YOU Control What

Goes In Your Body-Avoid 3

Food Felons

3. Call A Buddy

8. Avoid Other 2 Food Felons

For Your Brain

Avoid Other 2 Food Felons

That Rob Your Energy & Your

Memory

• Saturated Fat

• Trans Fat

DIET AND LIFESTYLE CHANGE GENE EXPRESSION

1 & 8Avoid 5 Food Felons That

Rob Your Energy & Your Memory

• Saturated Fat

• Trans Fat

• Sugar

• Simple Carbs (enriched flour)

• Syrup (corn, and others)…Blood

sugar less than 110 for heart;

less than 250 for brain

Alzheimer’s Disease

and Diabetes

•Diabetes increases the

risk of AD

•Diabetes increases the

progression of cognitive

decline in those with AD

1. KNOW YOU Control What

Goes In Your Body

6. Call A Buddy

9. Take 5 Pills

For Your Brain

1. DHA 900 MG

2. VITAMIN D3 1000 IU

3. CALC 600MG & MG 400 MG A

4. 1/2 MULTI 2 X A DAY

5. ASA 162 MG WITH H20

6. PROBIOTIC

7. MAYBE NON BBB STATIN & COQ10

FIVE PILLS

• FARMED FISH SAVE SALMON AND TROUT FROM SUPPLIERS ALL OVER USA LOW IN OMEGA-3’S

• Changes in diet during the past century have caused a

marked increase in consumption of saturated fatty acids

• and n-6 polyunsaturated fatty acids (PUFAs) with a concomitant

• decrease in the intake of n-3 PUFAs. Increased

• fish consumption has been shown to be the only realistic

• way to increase dietary quantities of beneficial long-chain

• n-3 PUFAs such as eicosapentaenoic acid and docosahexaenoic

• acid and re-establish more balanced n-6:n-3

• ratios in the diets of human beings. Our objective in this

• research was to characterize some of the relevant fatty

• acid chemistry of commonly consumed fish, with a particular

• focus on the four most commonly consumed

• farmed fish. To do this, 30 commonly consumed farmed

• and wild fish were collected from supermarkets and

• wholesalers throughout the United States. Fatty acid c o m -

• position of samples from these fish was determined

• using gas chromatography. The 30 samples studied contained

• n-3 PUFAs ranging from fish having almost undetectable

• levels to fish having nearly 4.0 g n-3 PUFA per

• 100 g fish. The four most commonly farmed fish, Atlantic

• salmon, trout, tilapia, and catfish, were more closely examined.

• This analysis revealed that trout and Atlantic

• salmon contained relatively high concentrations of n-3

• PUFA, low n-6:n-3 ratios, and favorable saturated fatty

• acid plus monounsaturated fatty acid to PUFA ratios. In

• contrast, tilapia ( the most frequently

• farmed fish) and catfish have much lower concentrations

• of n-3 PUFA, very high ratios of long chain n-6 to long

• chain n-3 PUFAs, and high saturated fatty acid plus

• monounsaturated fatty acid to PUFA ratios. Taken together,

• these data reveal that marked changes in the

• fishing industry during the past decade have produced

• widely eaten fish that have fatty acid characteristics that

• are generally accepted to be inflammatory by the health

• care community.

• J Am Diet Assoc. 2008;108:1178-1185.

IN LAST 10 YRS

FISH HARVESTING

CHANGED SO

MUCH THAT IN USA,

ONLY FISH WITH

DHA ARE SALMON

AND TROUT

1. DHA 900 MG

6. PROBIOTIC

FIVE PILLS

1. DHA 900 MG

6. PROBIOTIC

FIVE PILLS

Prenatal Multivitamins + DHA

• Decrease congenital birth defects

(major) by 80%

• Decrease childhood cancers by 65%+

• Decrease Autism & Autistic spectrum

disorders by 40%+ (if taken for 3

months prior to conception)s

• Improve IQ outcomes

Multivitamins + DHA +

Lutein after Age 55

• Insurance policy vs. imperfect diet

• 80-90% of employees tested are

deficient in D3 +/- at least one other

• Decrease memory loss w/ aging

• Decrease eyesight loss w/ aging

1. Know YOU Control What

Goes In Your Body

10. Sleep 6.5 to 8 hrs every day

For Your Brain

We Have A Program

For YOU 4 That–

“GO! To Sleep”

1. Know YOU Control What

Goes In Your Body

10. Sleep 6.5 to 8 hrs every day

11. Floss and See a Dental Pro

Every 6 Months

For Your Brain

12. Know Your BP and do

whatever to keep it at 115/75

13. Know Your CRP and do

whatever to keep it under 1.0

For Your Brain

14. Love Something & Do It

For Your Brain

Wellness : 5 Normals:The Cleveland · Start &Sustaining the change •Ah Moments—Your RealAge...

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