Cardiometabolic Research in the Cardiometabolic Research in the Center for Health Discovery and Center for Health Discovery and Well Being at Emory UniversityWell 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 HealthPredictive Healththe concept

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.

The majority of resourcesThe majority of resources

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.

Goal for Health systemGoal for Health system

for biomedical research has been slower to develop.

There is a need to focus the formidable power of the research enterprise-

basic, translational and clinicalon 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.

The shift in focus of biomedical researchThe shift in focus of biomedical research

This would provide essential tools for health surveillance, risk assessment and premorbid diagnosis as well as the knowledge base for interventions in essentially healthy people

that would preclude progression to end organ failure.

The shift from disease to healthThe shift from disease to health

Predictive HealthPredictive HealthDefinitionDefinition

“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 ContinuumThe Health/Disease Continuum

NormalLow risk

NormalHigh risk

Predisease

Earlydisease

Latedisease

Predictive Health

Contemporary Medicine

HEALTH

DISEASE

Predictive Health and Public HealthPredictive Health and Public HealthCongruenceCongruence

IMMUNE HEALTH

Determinantsof

Health

Generic Processes

INCREASED CAROTID

IMT

Pre-disease

DIABETES

NEURO-DEGENERATIVE

DISEASE

ATHERO-SCLEROSIS

PSYCHIATRICDISORDERS

CANCER

Disease

Protecting health: The territory

Role of Academic Health Role of Academic Health Centers in the Health Care Centers in the Health Care TransitionTransition

◦Multiple disciplines within one organization◦Creative mindset

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 Predictive Health: Systemic ImplicationsImplications

Education◦General public◦Politicians◦Health care professionals

Economics◦Government◦Insurers

Information technology

The Emory-Georgia Tech The Emory-Georgia Tech Predictive Health Predictive Health

InstituteInstitute

Predictive Health Institute Predictive Health Institute ThemesThemes

•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

Generic Pathways

Specific DiseasesCardiovascular

Diseases

Chronic Lung Diseases

Diabetes

Cancer

Neurological Diseases

Determinants of Health

Environment

Genetics Behavior

Oxidative Stress

Development and

Senescence

Regeneration and Repair

Other Generic Pathways

Immunology and

Inflammation

Technologies

Genomics/ Metabolomics/ Proteomics

Molecular Imaging

Bioinformatics

Nanomedicine

Quantitative Medicine

Novel Therapeutics

Education

Disciplines

Finance and Economics

Public Policy

Ethics

Systems Biology

Population Biology

The Emory Georgia Tech Center for The Emory Georgia Tech Center for Health Discovery and Well BeingHealth Discovery and Well Being

A partnership of discovery◦Discovering individual health◦Expanding knowledge of human health in

generalA new health care paradigm

◦Health focused◦Merging health care and research

A grand experiment◦Inventing a new health care model

Emory-Georgia Tech Center for Health Discovery and Well Being

Assessment: The SurveysAssessment: The Surveys

Surveys collect information aboutMental, Emotional &

Spiritual healthHealth Symptoms,

Exposure, Behavior & Physical Activity

Nutrition, Supplements & Medications

Stress, Anxiety, Depression & Sleep Patterns

Copyright 2005-2008 Emory University

Assessment: InstrumentationAssessment: Instrumentation

Resting Blood Pressure and Heart Rate

Anthropometrics & Body Composition% body fatLean Body MassBone Mineral Density

Treadmill Fit TestingVascular Testing

Arterial thicknessArterial elasticityCentral Blood

Pressure

Copyright 2005-2008 Emory University

Assessment Laboratory StudiesAssessment Laboratory Studies

More than 50 different lab tests

Known biomarkersEndocrine HealthImmune HealthMetabolic HealthInflammation

HealthNutrition Status

Research biomarkersOxidation StatusInflammation

StatusImmune FunctionRegenerative

Capacity

Copyright 2005-2008 Emory University

Health Assessment ReportHealth Assessment Report

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 PlanningHealth Action PlanningCollaboration with their Predictive Health PartnerParticipant empowerment & engagement in goal

settingWhat does this mean for the participant

Work-life balance Nutrition Physical activity Mental and emotional healthSpiritual healthHealth risk behaviors 

Personalized Health Action Plan (internal/external resources)

Follow up assessments

Role of Predictive Health PartnerRole of Predictive Health Partner

Relationship BuilderFacilitatorConsultantEducator TranslatorConfidantSpecialistCollaboratorNavigator

Predictive Health Predictive Health ResearchResearch

The Cardiometabolic Study

dyslipidemia, insulin resistance, elevated blood pressure and obesity/overweight commonly referred to as the metabolic syndrome. tend to cluster and clearly confer increased risk for the development of

atherosclerosis and consequent cardiovascular pathology

Cardiometabolic Risk Factors and the Metabolic Syndrome

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

Predictive HealthPredictive HealthThe Imminent Revolution in Health Care

A random sample of Emory’s 20,000 employees.

Upwards of 300 participants completed an initial evaluation and have been assigned a Health Partner. follow up evaluations at 6 months and one

year following enrollment. Drop out less than 2%

Study Population

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. Income distribution covers the range of

employees from <$50K per annum to >$200K per annum household income.

Demographics

The five criteria (ATPIII) that are generally accepted for diagnosing the metabolic syndrome are:

1) waist circumference >=40 inches in men or >=35 inches in women;

2) serum triglycerides >=150 mg/dL or drug treatment for elevated triglycerides;

3) HDL-C <40mg/dL in men or <50mg/dL in women or drug treatment for reduced HDL-C;

4) systolic blood pressure >= 130 mmHg or diastolic blood pressure >=85mmHg or drug treatment for hypertension; and

5) fasting blood glucose >= 100 mg/dL or drug treatment for elevated blood glucose.

Metabolic syndrome criteria

Figure 1: Percent of study participants to date by numbers of metabolic syndrome criteria met.

But that is only a part of the story.

A much larger number of healthy participants in this program are at significant cardiometabolic risk.

Additional 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)

variable Baseline (SD)Change @ 6mo

(paired mean and SD) P

Fasting glucose (mg/dl)

88.3(12.9) -2.1(8.1) 0.04

HDL (mg/dl) 67.4(19.4) 2.71(8.43) 0.01

CD34 count (cells/ul)

4.7(6.6) 2.75(8.05) 0.008

Total cysteine 168.4(35.7) 22.6(44.5) 0.007

Augmentation index28.88(10.34) 3.01(6.17) 0.0002

Mental quality of life (SF36)52.1(9.4) 3.88(7.8) 0.05

Beck depression scale4.6(5.3) -1.38(3.77) 0.0045

General anxiety (GAD7)3.94(3.1) -1.44(2.87) 0.07

Perceived stress (PSS)18.0(7.9) -2.6(6.5) 0.07

VO2max 47.5(14.2) 10.3(13.3) <0.0001

Systolic BP (mmHg)

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

Pilot data summaryPilot data summarycollected 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:

Waist circumferenceSerum triglyceride concentrationSerum high density lipoprotein (HDL-C)

concentrationSystolic or diastolic blood pressureFasting blood glucose concentration

Measurements of fundamental processes

Markers of oxidative stress

Markers of inflammation

Progenitor cell populations Immune markers

Measurements of cardiovascular

structure/function

Pulsatile arterial tonometry Arterial Stiffness/Compliance

Additional measures of cardiovascular structure/function:

Ultrasound-derived carotid artery intimal-medial thickness

VO2max (symptom-limited treadmill exercise test)

heart rate variability.

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:

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

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 Center processHealth assessment and plan Nutrition Physical activity Stress reduction Personalization of the plan Other Partner activitiesOngoing contact